London
9 July 2001

Mental Health and Social Inclusion

Dr Ghodse,

Distinguished Participants,

I am delighted to be here with you at your annual meeting, and at this regional meeting of the World Association of Psychiatrists. During this seminar on Mental Health and Social Inclusion, I would like to explore ways in which the international community of psychiatrists could promote equity in mental health.

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.

Today, more than 430 million people worldwide 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% 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% 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 second place.

The world over, there are on average twice as many women who are suffering from depression than men.

Between ten and 20 million people attempt suicide each year. More than 800 000 die.

Mr Chairman,

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.

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 people who undergo such experiences 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.

I witnessed the scars of war when I visited Kinshasa last week - a city that has doubled in size during recent years, as people have tried to escape the horrors of a brutal war. We are all humbled by the task facing us in helping people to rebuild their lives.

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 dollar a day.

We are working hard to confront this poverty, and contribute to its reduction. The task is huge. Predictions are that 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% increase in the size of this age group. And, by 2020, approximately 70% 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 19^th 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. In seventy-eight countries - or 43% of those studied - there is no policy for addressing mental health issues within the context of national efforts to improve public health. Thirty-seven countries - or 23% - have no legislation on mental health. Sixty-nine countries - or 38% - have no community care facilities, and in 73 countries - or 41% - treatment of severe mental illness is not available within primary health care. In 44% of the countries, expenditure on mental health makes up less than one per cent of the total health budget.

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% of those suffering from depression can fully recover if treated with antidepressant medication and cognitive psychotherapy. Fewer than 25% of those affected receive treatment.

• We know that the relapse rate of people with schizophrenic illness can be reduced by up to 60% if patients receive proper medication and families receive proper education and support. Still, only 25% of those at risk are able to access such care.

• We know that 80% of those who suffer from epilepsy could live a normal life if treated with anti-convulsive medication. Only 10% of sufferers in developing countries actually access such treatment.

• 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? 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, 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, mental health workers, media, consumers and advocates from eleven countries gathered 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.

Today, community clinics are mushrooming all over Chile and Brazil. In Central America, countries are adopting innovative responses. In Belize, for instance, where there is only one practising psychiatrist working in the country, human resources have multiplied through the training of psychiatric nurse practitioners, entrusted with the provision of mental health care. A recently conducted evaluation has shown that the public is satisfied with their services, now offered all over the country. Despite these improvements, there is still a long way to go to reach the aims of the Caracas Declaration.

We who are gathered here today know these realities. We also know that our ability to progress is limited by the shortage of health workers with mental health skills. Psychiatrists are a highly valued, but very rare, species. In more than half of the world's countries, there is less than one psychiatrist and psychiatric nurse per 100 000 people.

More specialists in mental health care are needed in many parts of the world. An increased psychiatrist-to-population ratio is possible, but will not be achieved for decades.

I know that this reality is appreciated by the psychiatric professions. You have a responsibility not only to practice, but to teach your skills to others. In this Royal College you are committed to improving the mental health skills of all health professionals. This approach is essential everywhere if we are to bring mental health into the mainstream of public health.

Inclusiveness must start within national professional associations, with a commitment to ensure a wide access to critical knowledge and skills.

Taken together, this means that all general medical and nursing practitioners:

• Know how to recognize the symptoms of mental illness and brain disorders.

• Are able to provide basic treatment to those who attend health facilities.

• Are linked together and supported by strong networks - particularly when providing first-contact mental health care.

• Are able to share information and experiences.

• Have the opportunity to develop their skills through a continuing emphasis on in-service training.

It means that mental health is central to analysis and planning for public health, and is given its proper place in health policies and planning.

Throughout the developing world the mental health professions are called on to enable other health workers to access their vital skills. But the need is also relevant here, in Europe. We can expect mental health professionals to look after the science. They will offer expert treatment and oversight of the quality of all mental health care. They will also be responsible for helping others respond to symptoms with effective diagnosis and treatment - whether for individual people, or for populations.

When general medical and nursing practitioners take responsibility for mental health practice, they can make enormous contributions.

Let me tell you a Norwegian story.

One late autumn day in 1995, a family of refugees arrived in a small village in central Norway. This family had witnessed how most of their own village’s population in Bosnia had been massacred, and they had been maltreated for months in prison camps. The husband, who had also served against his will in the army, had suffered a mental breakdown and was periodically psychotic and suffered from paranoia and deep trauma. Taking a chance, the local physician and the municipality’s psychologist went against the medical advice from Bosnia, which said the man needed hospitalization.

A year of close follow-up and dedicated work by the local doctor, the refugee coordinator and the local authorities had stabilized the family. The man had an internship in a local factory, the woman learned Norwegian and was included in local social activities, and the children functioned well at school.

Then the War Crimes Tribunal in the Hague wanted them to witness against the officers who had ordered the massacre in their village. This threw the man straight back into illness, with new psychotic spells and crippling attacks of anxiety. Again, the local physician chose not to go the way of the mental hospital. Instead he helped the family face their real problem - the traumas from the war. After a number of anguishing months, the family chose to testify at the Hague. By doing so, and by carrying it out, the man of the family managed to pull himself out of his own mental illness.

Today, the family lives a normal life in this village: they work, they are integrated into the local culture and they have no need for mental health care.

This example reminds us of the reality. Efforts to promote and maintain good mental health have to start with the affected individual in the family, and with the family unit. They continue through the work place and the local community. They draw support from the public health infrastructure and local authorities.

We have seen this in the Swedish island of Gotland. When the general physicians on this island were trained to detect early signs of depression, there was a considerable reduction in the suicide rate. This result confirms the crucial role that general physicians can play in mental health work.

Over the past two years at least 50% of general physicians in the Mongolian capital, as well as in several provinces, have received mental health training and started to manage patients with mental health problems in their clinics. They have included mental health topics in their health education activities in the schools and during their home visits. Although we are yet to assess the effectiveness of this new programme, it is a good example of how a developing country can benefit by leap-frogging fifty years of global experience in mental health care.

In the case of our Bosnian refugees in Norway, the local physician played a key role, but also the understanding of mental health problems by the refugee coordinator, the other support staff, and even the mayor of this small village played an important role in restoring the mental well-being of this family. In the end, it was an external factor - the therapeutic effects of truth and justice - which made the biggest difference.

This shows the importance of involving the whole of society in the treatment and care of mental ill-health, and in public health aspects of mental illness.

We know the critical importance of involving families. They face enormous burdens, particularly when efforts are made to promote the care of mentally ill people within their communities.

Families need help to cope with new burdens - burdens that might have been less apparent when family members with mental illness were incarcerated - automatically. We must all work hard to enable people affected by mental illness to be treated not only as individuals but as members of family units. They will need the information, respect and support required to reach decisions on how best to help a mentally-ill family member to live as full a life as possible.

We have learnt of the damage that can be caused by the hasty closure of mental health facilities with inadequate financial and professional support for primary mental health care, community facilities and for family units. The closure should not be the result of a process designed to make financial savings. Good community care can be more costly than the minimalist institutional care currently available in many countries.

We have seen real reforms in mental health care during the past twenty years within different countries. The quality of treatment and care have improved beyond recognition, with increased attention to the well-being of the patient rather than the needs of the system. But we still have a long way to go.

Indeed, even in Europe there are more than 100 very large psychiatric hospitals. Many of these are reported to be in a poor condition, sometimes offering inhumane and outmoded care. We need to work together to focus on improving the effectiveness of treatment for mental illness, on their access to medicines, and on the extent to which the human rights of patients with mental illnesses are realized.

These means always putting the interests of the patient at the centre of mental health action. Sometimes, though, the fears and concerns of society, the health workers - and more rarely, the family - may take precedence.

Mr Chairman,

Now our main struggle is to ensure wider access to effective mental health care - including medicines and cognitive therapies - especially in countries and communities that cannot afford them.

One-third of the world’s population has no access to even the most basic psychotropic medicines.

We know that fewer than 25% of the people suffering from depression in countries with established market economies receive treatment. In other countries, such as in sub-Saharan Africa and China, treatment rates for depression are as low as 5%.

Over the past thirty years we have seen a fantastic increase in the number of effective medications which have revolutionized our ability to treat and reduce the effects of mental disorders.

Even in industrialized countries, psychiatrists report that fear and stigma still cause patients to resist taking medicines they need. At the same time, there is a need to ensure that prescribing for mental illness is rational, taking account of the diagnosis, context and patient's need. There is a reported tendency to over-prescribe which is best addressed through effective training of all health professionals, coupled with high quality public information.

The pharmaceutical industry is providing a range of psychotropic medications that are greatly assisting us in improving the lives of our patients. In this sense we are working in partnership for a common good. There is a constant challenge in our collaboration with industry - both at institutional and personal levels. The starting point is that we should all be clear about our respective roles and limitations. And there is a strong imperative to identify, and avoid, conflicts of interest in the work we do.

Mr Chairman,

We are in the middle of a year that WHO has dedicated to mental health. We saw an impressive global response to the World Health Day.

The forthcoming World Health Report, which this year focuses on mental health, will provide a firm global overview of the current and future burden of mental ill health and their main contributing factors. It will review what we know about effective interventions for prevention and care and the barriers to using these interventions. It will also outline the policies needed to ensure that stigma and discrimination are broken down. It will contain strategies for ensuring that effective prevention and treatment are both put in place and adequately funded.

These activities have put mental health higher up on the global public health agenda. In doing so we have created expectations that will help us deliver equitable mental health outcomes.

I am delighted to learn that the Royal College of Psychiatrists has set up a Board of International Affairs. This board will promote collaboration on mental health policies and research with developing countries. It will make an important contribution to reducing the health gap between rich and poor countries. Industrialized-country mental health professionals can take this action and contribute to global progress in mental health. I am looking forward to our future collaboration on these key issues.

WHO is ready to work with you on global initiatives, and Dr Benedetto Saraceno, WHO's Director of Mental Health, will speak more about how we hope to do this later in the week.

So , finally, let me say this:

Our message is one of concern and hope.

The road ahead is long and difficult. We know it is littered with myths, secrecy and sometimes shame.

But this new century is nothing if not a time of opportunity and challenge. Let us use the inspiration and the momentum provided by this year's focus on mental health to go back to our work places and our local communities and make a change.

Let us stop Exclusion!

Let us Dare to Care!

Thank you.