Chapter 4: Mental Health Policy and Service Provision : Previous page | 1,2,3,4,5

Involving other sectors

Chapter 4 Developing policy Providing services Promoting mental health Involving other sectors Promoting research

War, conflict, disasters, unplanned urbanization, and poverty are not only important determinants of mental ill-health but are also significant barriers to reducing the treatment gap. For example, war and conflict can destroy national economies and health and welfare systems, and can traumatize entire populations. With poverty comes an increased need for health and community services but a limited budget to develop comprehensive mental health services at the national level and a reduced ability to pay for these services at the individual level.

Mental health policy can partially address the effects of environmental determinants by meeting the special needs of vulnerable groups and ensuring that strategies are in place to prevent exclusion. But because many of the macro-determinants of mental health cut across almost all government departments, the extent of improvement in mental health of a population is also in part determined by the policies of other government departments. In other words, other government departments are responsible for some of the factors involved in mental and behavioural disorders, and should take responsibility for some of the solutions.

Intersectoral collaboration between government departments is fundamental in order for mental health policies to benefit from mainstream government programmes (see Table 4.2). In addition, mental health input is required to ensure that all government activities and policies contribute to and do not detract from mental health. Policies should be analysed for their mental health implications before being implemented, and all government policies should address the specific needs and issues of persons suffering from mental disorders. Some examples are provided below.

Table 4.2 Intersectoral collaboration for mental health

Labour and employment

The work environment should be free from all forms of discrimination as well as sexual harassment. Acceptable working conditions have to be defined and mental health services provided, either directly or indirectly through employee assistance programmes. Policies should maximize employment opportunities for the population as a whole, and retain people in the workforce, particularly because of the association between job loss and the increased risk of mental disorders and suicide. Work should be used as a mechanism to reintegrate persons with mental disorders into the community. People with severe mental disorders have higher unemployment rates than people with physical disabilities. Government policy can be instrumental in providing incentives for employers to employ persons with severe mental disorders and enforcing anti-discrimination policy. In some countries, employers are obliged to hire a certain percentage of disabled persons as part of their workforce. If they fail to do so, a fine can be imposed.

Commerce and economics

Some economic policies may negatively affect the poor, or lead to increased rates of mental disorders and suicide. Many of the economic reforms under way in countries have as a major goal the reduction of poverty. Given the association between poverty and mental health, it might be expected that these reforms would reduce mental problems. However, mental disorders are not only related to absolute poverty levels but also to relative poverty. The mental health imperatives are clear: inequalities must be reduced as part of strategies to increase absolute levels of income.

A second challenge is the potential adverse consequences of economic reform on unemployment rates. In many countries undergoing major economic restructuring, for example, Hungary (Kopp et al. 2000) and Thailand (Tangchararoensathien et al. 2000), reform has led to high job losses and an associated increase in the rates of mental disorders and suicides. Any economic policy involving restructuring must be evaluated in terms of its potential impact on employment rates. If there are potentially adverse consequences, then these policies need to be reconsidered or strategies need to be put in place to minimize the impact.

Education

An important determinant of mental health is education. While current efforts focus on increasing the numbers of children attending and completing primary school, the main risk for mental health is more likely to result from a lack of secondary-school education (10­12 years of schooling) (Patel 2001). Strategies for education therefore need to prevent attrition prior to the completion of secondary school. The relevance of the type of education offered, freedom from discrimination at school, and the needs of special groups, for example children with learning disabilities, also need to be considered.

Housing

Housing policy can support mental health policy by giving priority to mentally ill people in state housing schemes, providing subsidized housing schemes and, where practical, mandating local authorities to establish a range of housing facilities such as halfway homes and long-stay supported homes. Most importantly, housing legislation must include provisions to prevent the geographical segregation of mentally ill people. This requires specific provisions to prevent discrimination in siting and allocation of housing as well as health facilities for persons with mental disorders.

Other social welfare services

The type, range and extent of other social welfare services varies across and within countries and is partly dependent on levels of income and the general attitude of the community towards groups in need.

Policies for social welfare benefits and services should incorporate a number of strategies. First, the disability resulting from mental illness should be one of the factors taken into account in setting priorities among groups receiving social welfare benefits and services. Second, under some circumstances, social welfare benefits should also be available to families that provide the care and support to family members suffering from mental and behavioural disorders. Third, staff working in the various social services need to be equipped with the knowledge and skills to recognize and assist people with mental disorders as part of their daily work. In particular they should be able to evaluate when and how to refer the more severe problems to specialized services. Fourth, welfare benefits and services need to be mobilized for groups likely to be adversely affected by the implementation of economic policy.

Criminal justice system

People with mental disorders often come into contact with the criminal justice system. In general, there is an over-representation of people with mental disorders and vulnerable groups in prisons, in a number of cases because of lack of services, because their behaviour is seen as disorderly and because of other factors such as drug-related crime and driving under the influence of alcohol. Policies should be put in place to prevent the inappropriate imprisonment of the mentally ill and to facilitate their referral or transfer to treatment centres instead. Furthermore, treatment and care for mental and behavioural disorders should be routinely available within prisons, even when imprisonment is appropriate. International standards with regard to the treatment of prisoners are set out in the Standard Minimum Rules for the Treatment of Prisoners which provide that the services of at least one qualified medical officer "who should have some knowledge of psychiatry" shall be available at every institution (adopted by the First United Nations Congress on the Prevention of Crime and the Treatment of Prisoners in 1955 and approved by the Economic and Social Council in 1957 and 1977).

Policy concerning the confinement of vulnerable groups needs to be examined in relation to the increased risk of suicide, and there needs to be a training strategy to improve the knowledge and skills of staff in the criminal justice system to enable them to manage mental and behavioural disorders.

Chapter 4: Mental Health Policy and Service Provision : 1,2,3,4,5 | Next page