Outline of the World Health Report
Chapter 1 introduces the reader to a new understanding of mental health and explains why it is as important as physical health to the overall well-being of individuals, families, societies and communities.
Mental and physical health are two vital strands of life that are closely interwoven and deeply interdependent. Advances in neuroscience and behavioural medicine have shown that, like many physical illnesses, mental and behavioural disorders are the result of a complex interaction between biological, psychological and social factors.
As the molecular revolution proceeds, researchers are becoming able to see the living, feeling, thinking human brain at work and to see and understand why, sometimes, it works less well than it could. Future advances will provide a more complete understanding of how the brain is related to complex mental and behavioural functioning. Innovations in brain imaging and other investigative techniques will permit "real time cinema" of the nervous system in action.
Meanwhile, scientific evidence from the field of behavioural medicine has demonstrated a fundamental connection between mental and physical health -for instance, that depression predicts the occurrence of heart disease. Research shows that there are two main pathways through which mental and physical health mutually influence each other.
Physiological systems, such as neuroendocrine and immune functioning, are one such pathway. Anxious and depressed moods, for example, initiate a cascade of adverse changes in endocrine and immune functioning, and create increased susceptibility to a range of physical illnesses.
Health behaviour is another pathway and concerns activities such as diet, exercise, sexual practices, smoking and adhering to medical therapies. The health behaviour of an individual is highly dependent on that person's mental health. For example, recent evidence has shown that young people with psychiatric disorders such as depression and substance dependence are more likely to engage in smoking and high-risk sexual behaviour.
Individual psychological factors are also related to the development of mental disorders. The relationships between children and their parents or other caregivers during childhood are crucial. Regardless of the specific cause, children deprived of nurture are more likely to develop mental and behavioural disorders either in childhood or later in life. Social factors such as uncontrolled urbanization, poverty and rapid technological change are also important. The relationship between mental health and poverty is particularly important: the poor and the deprived have a higher prevalence of disorders, including substance abuse. The treatment gap for most mental disorders is high, but for the poor population it is indeed massive.
Chapter 2 begins to address the treatment gap as one of the most important issues in mental health today. It does so first of all by describing the magnitude and burden of mental and behavioural disorders. It shows they are common, affecting 20-25% of all people at some time during their life. They are also universal affecting all countries and societies, and individuals at all ages. The disorders have a large direct and indirect economic impact on societies, including service costs. The negative impact on the quality of life of individuals and families is massive. It is estimated that, in 2000, mental and neurological disorders accounted for 12% of the total disability-adjusted life years (DALYs) lost due to all diseases and injuries. By 2020, it is projected that the burden of these disorders will have increased 15%. Yet only a small minority of all those presently affected receive any treatment.
The chapter introduces a group of common disorders that usually cause severe disability, and describes how they are identified and diagnosed, and their impact on quality of life. The group includes depressive disorders, schizophrenia, substance use disorders, epilepsy, mental retardation, disorders of childhood and adolescence, and Alzheimer's disease. Although epilepsy is clearly a neurological disorder, it is included because it has been seen historically as a mental disorder and is still considered this way in many societies. Like those with mental disorders, people with epilepsy suffer stigma and also severe disability if left untreated.
Factors determining the prevalence, onset and course of all these disorders include poverty, sex, age, conflict and disasters, major physical diseases, and family and social environment. Often, two or more mental disorders occur together in an individual, anxiety and depressive disorders being a common combination.
The chapter discusses the possibility of suicide associated with such disorders. Three aspects of suicide are of public health importance. First, it is one of the main causes of death of young people in most developed countries and in many developing ones as well. Second, there are wide variations in suicide rates across countries, between the sexes and across age groups, an indication of the complex interaction of biological, psychological and sociocultural factors. Third, suicides of younger people and of women are a recent and growing problem in many countries. Suicide prevention is among the issues discussed in the next chapter.
Chapter 3 is concerned with solving mental health problems. It highlights one key issue in the whole report, and one that features strongly in the overall recommendations. This is the positive shift, recommended for all countries and already occurring in some, from institutionalized care, in which the mentally disordered are held in asylums, custodial-type hospitals or prisons, to care in the community backed by the availability of beds in general hospitals for acute cases.
In 19th-century Europe, mental illness was seen on one hand as a legitimate topic for scientific enquiry: psychiatry burgeoned as a medical discipline, and people suffering from mental disorders were considered medical patients. On the other hand, people with these disorders, like those with many other diseases and undesirable social behaviour, were isolated from society in large custodial institutions, the state lunatic asylums, later known as mental hospitals. The trends were later exported to Africa, the Americas and Asia.
During the second half of the 20th century, a shift in the mental health care paradigm took place, largely owing to three independent factors. First, psychopharmacology made significant progress, with the discovery of new classes of drugs, particularly neuroleptics and antidepressants, as well as the development of new forms of psychosocial interventions. Second, the human rights movement became a truly international phenomenon under the sponsorship of the newly created United Nations, and democracy advanced on a global basis. Third, a mental component was firmly incorporated into the concept of health as defined by the newly established WHO. Together these events have prompted the move away from care in large custodial institutions to more open and flexible care in the community.
The failures of asylums are evidenced by repeated cases of ill-treatment to patients, geographical and professional isolation of the institutions and their staff, weak reporting and accounting procedures, bad management and ineffective administration, poorly targeted financial resources, lack of staff training, and inadequate inspection and quality assurance procedures.
In contrast, community care is about providing good care and the empowerment of people with mental and behavioural disorders. In practice, community care implies the development of a wide range of services within local settings. This process, which has not yet begun in many regions and countries, aims to ensure that some of the protective functions of the asylum are fully provided and that the negative aspects of the institutions are not perpetuated.
The following are characteristics of providing care in the community:
- services which are close to home, including general hospital care for acute admissions, and long-term residential facilities in the community;
- interventions related to disabilities as well as symptoms;
- treatment and care specific to the diagnosis and needs of each individual;
- a wide range of services which address the needs of people with mental and behavioural disorders;
- services which are coordinated between mental health professionals and community agencies;
- ambulatory rather than static services, including those which can offer home treatment;
- partnership with carers and meeting their needs;
- legislation to support the above aspects of care.
However, this chapter warns against closing mental hospitals without community alternatives and, conversely, creating community alternatives without closing mental hospitals. Both have to occur at the same time, in a well-coordinated, incremental way. A sound de-institutionalization process has three essential components:
- prevention of inappropriate mental hospital admissions through the provision of community facilities;
- discharge to the community of long-term institutional patients who have received adequate preparation;
- establishment and maintenance of community support systems for non-institutionalized patients.
In many developing countries, mental health care programmes have a low priority. Provision is limited to a small number of institutions that are usually overcrowded, understaffed and inefficient. Services reflect little understanding of the needs of the ill or the range of approaches available for treatment and care. There is no psychiatric care for the majority of the population. The only services are in large mental hospitals that operate under legislation which is often more penal than therapeutic. They are not easily accessible and become communities of their own, isolated from society at large.
Despite the major differences between mental health care in developing and developed countries, they share a common problem: many people who could benefit do not take advantage of available psychiatric services. Even in countries with well-established services, fewer than half of those individuals needing care make use of such services. This is related both to the stigma attached to individuals with mental and behavioural disorders, and to the inappropriateness of the services provided.
The chapter identifies important principles of care in mental health. These include diagnosis, early intervention, rational use of treatment techniques, continuity of care, and a wide range of services. Additional principles are consumer involvement, partnerships with families, involvement of the local community, and integration into primary health care. The chapter also describes three fundamental ingredients of care - medication, psychotherapy and psychosocial rehabilitation - and says a balanced combination of them is always required. It discusses prevention, treatment, and rehabilitation in the context of the disorders highlighted in the report.
Chapter 4 deals with mental health policy and service provision. To protect and improve the mental health of the population is a complex task involving multiple decisions. It requires priorities to be set among mental health needs, conditions, services, treatments, and prevention and promotion strategies, and choices to be made about their funding. Mental health services and strategies must be well coordinated among themselves and with other services, such as social security, education, and public interventions in employment and housing. Mental health outcomes must be monitored and analysed so that decisions can be continually adjusted to meet emerging challenges.
Governments, as the ultimate stewards of mental health, need to assume the responsibility for ensuring that these complex activities are carried out. One critical role in stewardship is to develop and implement policy. This means identifying the major issues and objectives, defining the respective roles of the public and private sectors in financing and provision, and identifying policy instruments and organizational arrangements required in the public and possibly in the private sectors to meet mental health objectives. It also means prompting action for capacity building and organizational development, and providing guidance for prioritizing expenditure, thus linking analysis of problems to decisions about resource allocation.
The chapter looks in detail at these issues, beginning with options for financing arrangements for the delivery of mental health services, while noting that the characteristics of these should be no different from those for health services in general. People should be protected from catastrophic financial risk, which means minimizing out-of-pocket payments in favour of prepayment methods, whether via general taxation, mandatory social insurance or voluntary private insurance. The healthy should subsidize the sick through prepayment mechanisms, and a good financing system will also mean that the well-off subsidize the poor, at least to some extent.
The chapter goes on to discuss the formulation of mental health policy, which it notes is often developed separately from alcohol and drug policies. It says mental health, alcohol and drug policies must be formulated within the context of a complex body of government health, welfare and general social policies. Social, political and economic realities must be recognized at local, regional and national levels.
Policy formulation must be based upon up-to-date and reliable information concerning the community, mental health indicators, effective treatments, prevention and promotion strategies, and mental health resources. The policy will need to be reviewed periodically.
Policies should highlight vulnerable groups with special mental health needs, such as children, the elderly, and abused women, as well as refugees and displaced persons in countries experiencing civil wars or internal conflicts.
Policies should also include suicide prevention. This means, for example, reducing access to poisons and firearms, and detoxifying domestic gas and car exhausts. Such policies need to ensure not only care for individuals particularly at risk, such as those with depression, schizophrenia or alcohol dependence, but also the control of alcohol and illicit drugs.
The public mental health budget in many countries is mainly spent on maintaining institutional care, with few or no resources being made available for more effective services in the community. In most countries, mental health services need to be assessed, reevaluated and reformed to provide the best available treatment and care. The chapter discusses three ways of improving how services are organized, even with limited resources, so that those who need them can make full use of them. These are: shifting care away from mental hospitals, developing community mental health services, and integrating mental health services into general health care.
Other matters discussed in this chapter include ensuring the availability of psychotropic drugs, creating intersectoral links, choosing mental health interventions, public and private roles in provision of services, developing human resources, defining roles and functions of health workers, and promoting not just mental health but also the human rights of people with mental disorders. In this latter instance, legislation is essential to guarantee that their fundamental human rights are protected.
Intersectoral collaboration between government departments is essential in order for mental health policies to benefit from mainstream government programmes. In addition, mental health input is required to ensure that all government activities and policies contribute to and not detract from mental health. This involves labour and employment, commerce and economics, education, housing, other social welfare services and the criminal justice system.
The chapter says that the most important barriers to overcome in the community are stigma and discrimination, and that a multilevel approach is required, including the role of the mass media and the use of community resources to stimulate change.
Chapter 5 contains the recommendations and three scenarios for action listed at the beginning of this overview. It brings the report to an optimistic end, by emphasizing that solutions for mental disorders do exist and are available. The scientific advances made in the treatment of mental disorders mean that most individuals and families can be helped. In addition to effective treatment and rehabilitation, strategies for the prevention of some disorders are available. Suitable and progressive mental health policy and legislation can go a long way towards delivering services to those in need. There is new understanding, and there is new hope.