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Ladies and Gentlemen,
It is a great pleasure for me to be back in Norway
and speaking about mental health with the freedom that comes from
speaking as a physician - and not as a politician. As a physician, and
later as a Prime Minister, I saw for myself how hard it was to
strengthen mental health policies. 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 - and separated from - 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.
During the last three years, the World Health
Organization has 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.
Today, more than 430 million people world wide are
estimated to be suffering at any given time from some kind of mental
or neurological disorder, including alcohol and substance abuse
disorders.
Mental disorders account for 12 per cent of the
burden of all disease in 2000. Too few people realize that they are a
major cause of lost healthy years of life. The overall percentage is
expected to increase to 15 per cent over the next 20 years.
Depression, schizophrenia, bipolar disorders,
alcohol dependence, and obsessive-compulsive disorders are all to be
found among the ten leading causes of disability.
The burden of depressive illness is rising.
Currently it is ranked fourth among the 10 leading causes of the
global burden of disease. We estimate that by 2020, it will have
jumped to the second place.
The world over, there are on average twice as many
women who are suffering from depression than men.
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.
Closely linked to depression is the serious and
growing issue of alcohol and substance abuse. World wide, 5 per cent
of all deaths of young people between the ages of 15 and 29 are
attributable to alcohol use.
In Europe, one in four deaths of men in the age
group 15 to 29 is related to alcohol. In parts of Eastern Europe, the
figure is as high as one in three. All in all, 55 000 young people in
this region died from causes related to alcohol use in 1999. That is a
shocking and tragic waste.
Globally, 140 million people are suffering from
alcohol dependence. Around the world, alcohol takes a heavy toll -
damaging public and private life with countless traffic fatalities and
injuries, home fires, drownings, suicides and violent crimes. But also
debt problems, ruined careers, divorces, birth defects, and children
with permanent emotional damage.
Abuse of illegal drugs is a smaller - but still a
serious problem. In addition to the social and mental problems
associated with it, intravenous drug use is a major factor for the
spread of HIV/AIDS.
Between ten and 20 million people attempt suicide
each year. More than 800 000 die. Also here, the young are most at
risk. We have seen a disturbing shift in global suicide rates over the
past 50 years. In 1950, the 5-44 years age group accounted for 44 per
cent of cases of suicides. By 1995, this age group had begun to
dominate, accounting for 53 per cent of the suicides. In one third of
countries, suicide rates are higher among the under 30s than the older
groups. Also, the total number of youth suicides is increasing. This
has also been the case in the Nordic countries and in particular in
Norway.
Some of this growth is caused by more effective
methods for committing suicides. But still, the fact is that an
increasing number of young people find it impossible to live in our
modern world. This is a tragic trend.
Mental disorders have clear economic costs.
Sufferers and their families or caregivers 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.
Wherever economic costs of mental disorders have
been studied, the figures are staggering. The most comprehensive set
of estimates come from the United States, with the total economic
burden calculated at US $148 billion per year. In total, the costs of
mental disorders accounted for about 2.5 per cent of the USA’s
gross national product. A considerable proportion of these total costs
was attributable to work disability and associated productivity
losses.
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 even by people living in the calmest
and most prosperous corners of the world. We encounter newness at a
breath-taking pace: from new technology to new jobs to new fashions in
entertainment and culture. We 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.
In large parts of the developing world,
urbanization, rapid economic development and environmental degradation
are forcing billions of people to face a future very different from
what they experienced when they grew up. Few of their acquired skills
are able to assist them as they try to confront the new era.
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. Although some will thrive on new
opportunities, most of us - at times - are overwhelmed by the
challenges of multiple choices. We find them hard to handle.
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.
Consider, for example, the impact of conflict -
particularly violent conflict - on the lives of poor people.
People are displaced. Their families units are
dislocated. Support structures within communities are fractured. They
have to cope with stress and trauma - of bereavement, of losing
contact with relatives and friends and not knowing when - or even if -
they will see them again.
In some cases they are scarred by physical and
sexual abuse - even having to witness this abuse being meted out on
those they love.
We know that most people manage to cope with the
stress, and that people who don't, can be helped with professional
attention and care. But we are not talking about isolated cases here.
We are talking about tens of thousands, even hundreds of thousands of
people.
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 considerable 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 dollar a
day.
We are working hard to confront this poverty, and
contribute to its reduction. The task is huge. Predictions are that -
unless we instigate substantial change, most of the world's poor
cannot count on a substantial per capita income growth in the years to
come. We must find ways to enable poor people to benefit from the
positive features of globalization.
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. They tell
us they want to be able to influence what happens in their own lives
and to be able to make choices. Higher income is necessary, but not
sufficient.
The concept of "peace of mind" is key. When
we talk about mental health, we are quick to stress that what we are
aiming for is not only the absence of mental disorders. We want to
encourage mental well-being, a state in which individuals can
realize their abilities, can cope with the stresses of life, can work
productively and satisfactorily and make positive contributions to
their societies.
Obviously, poverty, both real and relative, is a
great obstacle to the achievement of this peace of mind.
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.
The evidence shows how important it is for us to
respond to the growing global burden of mental ill health. Let us now
consider the effectiveness of our collective efforts right now.
For centuries, there was little to do to treat
mental and brain disorders. During the 19th century,
humanistic reforms of mental care only meant building nicer asylums to
hide the mentally ill from the rest of us.
Public fear of insanity undermined efforts to
reform mental health policies. In 1959, WHO reported that "great
numbers of mentally ill people are still shut away behind hopeless
walls by the prejudices and incomprehension of society. The efforts (…)
to have the mentally ill treated as other sick people who can be
cured, are likely to remain fruitless as long as irrational fear of
‘madness’ is not conquered, as long as all the influential members
of the social hierarchy do not understand that mental health is not
only the business of specialists but must concern the whole
community."
A recent survey undertaken by WHO showed that the
situation has not changed much in the last 40 years. We
studied health policies in 185 of our 192 Member States.
Analyses have revealed that:
- More than 40 per cent (41 per cent) of countries do not have a
mental health policy;
-
A quarter (25 per cent) of the countries
have no legislation on mental health;
-
Almost 30 per cent (28 per cent) have no
separate budget for mental health;
-
Well over a third (37 per cent) of
countries do not have mental health community care facilities;
-
A quarter (25 per cent) of countries do
not have access to basic psychiatric medication at the primary
care level;
-
More than a quarter (27 per cent) of
countries do not have a system for collecting and reporting mental
health information;
-
Around 65 per cent of the beds for mental
health care are in separated mental hospitals;
-
Seventy per cent of the world’s
population has access to less than one psychiatrist per 100,000
people.
Globally, the mental health resources in countries
present a dismal picture of severe shortage and neglect. Often, the
resources and services are at 1 per cent to 10 per cent of what is
needed.
Closer analyses of the data, however, reveal that
countries are beginning to act. A large number of countries have
established policies and legislation in the past five years. NGOs,
consumer and family organizations are starting to become active in all
regions. Systematic efforts by governments and international agencies
such as WHO can catalyze this new energy to improve the mental health
situation around the world.
We have no excuses for continuing to keep those who
are mentally ill on the margins of public health action. We have made
enormous progress in the development of effective treatments for most
mental disorders. Further improvements are likely thanks to rapid
advances in understanding of how the brain works. Currently, there are
cost-effective interventions which enable most persons with mental,
brain or behavioural disorders to become functioning and productive
members of their communities, and to live normal lives.
Our better understanding of the inter-relations
between biological, psychological and social determinants of mental
disorders has given us much more knowledge about how to prevent many
conditions. At the same time, we know how early detection and
intervention can reduce the duration and severity of an individual's
mental illness.
Yet, the evidence on the access to mental health
care shows how far we still have to go. The gap between the numbers of
people who suffer, and the numbers who receive treatment and care, is
massive.
- We know that 70 per cent of those suffering from depression can
fully recover if treated with antidepressant medication and
cognitive psychotherapy. Fewer than 25 per cent of those affected
receive treatment.
-
We know that the relapse rate of people
with schizophrenic illness can be reduced by up to 60 per cent if
patients receive proper medication and families receive proper
education and support. Still, only 25 per cent of those at risk
are able to access such care.
-
We know that mental health consequences
of iodine deficiency can easily be prevented through iodine
supplementation of salt. However, despite two decades of intense
promotion, this cost-effective intervention is still not
universally implemented.
Why is the situation so unsatisfactory? Because mental
illness is still a taboo subject. 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, 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. The
mentally ill are often outcasts in their local society. 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.
A group of parliamentarians, professional NGOs,
mental health workers, media, consumers and advocates from eleven
countries were gathered by WHO in Venezuela in the early 1990s to
analyse mental health care and suggest ways to upgrade it. The Caracas
Declaration, which resulted from this historic meeting, has given
further impetus to a movement of reform in mental health care that was
on the making in several countries of Latin America.
To improve the mental health of populations, it is
essential for governments to commit to a systematic and proactive
strategy. The World Health Report 2001, based on scientific and
technical evidence for what works, has recommended ten feasible
solutions to address current and future mental health needs:
- Provide treatment in primary care
-
Make psychotropic medicines available
-
Give care in the community
-
Educate the public
-
Involve communities, families and
consumers
-
Establish national policies, programmes,
and legislation
-
Develop human resources
-
Link with other sectors
-
Monitor community mental health
-
Support more research
None of these recommendations is beyond the reach
of countries - if technical and financial support is made available.
Collectively, these recommendations can help close the gap between the
current mental health situation and that which can be achieved.
In the Islamic Republic of Iran, efforts to
integrate mental health care started in the late 1980s and the
programme has since been extended to the whole country, with services
now covering about 20 million people.
During a period of 10 years, Chile also has been
able to make remarkable achievements: the number of psychiatrists
working in public services has doubled; long stay beds have been
decreased by over 30 per cent in favour of community-based care;
and more than 40 consumer and family advocacy groups have been
established.
As remarkable as their accomplishments have been,
the stories of these countries should not be the exceptional cases:
with systematic guidance and support, other countries can achieve
similar successes.
In particular for children and the young,
prevention is crucial if we are to reduce the burden of substance
abuse, depression and suicides. The responsibility for good mental
health prevention sits with the family, the school, the work place,
and the local community. But above all it sits with the government and
the political institutions. Only if the government provides enabling
policies can these other entities make the decisions they need to
promote good mental health and prevent disorders.
Governments and parliaments need to mandate - and
equip schools and work places to carry out activities that prevent
mental ill health. This must include addressing the goals of primary
and secondary schooling with education leaders and devising ways to
make schools child friendly.
The teaching of "life skills" is one such
way of addressing these needs. WHO has developed a programme to
promote the teaching of such "life skills" in schools. These
are personal and interpersonal, psychological skills that can help the
children in their everyday life.
This includes skills to cope with stress, decision
making skills, problem solving, creative and critical thinking, as
well as communication and empathic skills. Assertiveness skills, if
used appropriately can prevent people suffering by being pushed about
and humiliated unjustly. These skills can also help in resisting
pressure from peers to join activities which the child might not
otherwise wish to.
Mental health has been a central theme for WHO all
through this year. The annual World Health Day was dedicated to mental
health, and so was this year's World Health Report. But our engagement
does not end here. These days, WHO is launching a major, new Mental
Health Global Action Programme.
This Global Action Programme was designed to
provide a clear and coherent strategy for closing the gap
between what is urgently needed, and what is currently available to
reduce the burden of mental disorders, world wide.
This past year has shown us that most countries
world-wide have the political will to improve their country's mental
health situation. Many of them, however, ask for assistance in how
they best should proceed. The Global Action Programme is our response
to these requests.
It is a five-year programme, which will require US
$34 million in funding and which will focus upon forging strategic
partnerships to enhance countries’ capacity to
comprehensively address the stigma and burden of mental disorders.
Through focusing on priority conditions, the programme will increase
governments’ awareness and responsiveness to mental health issues;
enhance the quality and effectiveness of mental health services;
reduce stigma and discrimination; and by doing so, take important
steps toward reducing the burden of a range of conditions and
enhancing the mental health of the population.
Four core strategies will be employed: 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.
WHO will work with governments to move mental
health towards the centre of health agendas. A momentum has been
created. But we can't leave this work to the health departments alone.
We all need to act together to secure real gains.
It is a heavy responsibility, but an exciting one.
Together, through the application of science and
extraordinary personal commitment, we will stop exclusion and dare
to care.
Thank you.
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