1.
Data la potenza economica delle industrie psicofarmaceutiche, che con la loro lobbies operano una pressione costante sulle istituzioni, sulla classe medica e sull’opinione pubblica, non c’è da sorprendersi di nulla.
La strategia delle industrie psicofarmaceutiche è chiara da tempo. La progressiva crescita dei fenomeni psicopatologici in tutto il mondo, con un tasso inquietante nei paesi sviluppati occidentali e uno preoccupante anche nei paesi in via di sviluppo, aprono alle industrie un mercato potenziale che coinvolge un abitante su cinque del pianeta. Le previsioni danno per scontato che, mantenendosi l’attuale trend, la percentuale, tra venti anni, è destinata ad aumentare, coinvolgendo un quarto della popolazione mondiale.
In gioco, insomma, è un mercato potenziale di un miliardo e passa di persone. Il problema delle industrie è come far convergere la domanda di cura, implicita nella sofferenza psicologica, e l’offerta che, sul piano di un intervento rapido e immediato è identificato con la prescrizione di psicofarmaci.
E’ evidente che questo tipo di approccio salta a piè pari l’analisi della domanda. Oggettivando il disagio psichico come espressivo di una potenzialità intrinseca all’apparato mentale umano, le industrie lo assumono come un dato di fatto che pone un problema di ordine pratico. Analizzare il fenomeno in tutte le sue componenti, comprenderlo e spiegarlo scientificamente per impostare programmi di prevenzione? Sì, certo, è importante. Ma nell’immediato come rispondere all’urlo di dolore che sale dalle viscere del mondo? Cosa dire a chi è affetto da insonnia, ansia, depressione, ecc.: che deve rassegnarsi e augurarsi che i figli e i nipoti siamo messi al riparo dal male oscuro?
In ogni orientamento umanitarista c’è (anche se non sempre, ovviamente) qualcosa di autenticamente spregevole. Molti anni fa Sartre pose provocatoriamente il problema di come sarebbero vissuti tanti cristiani samaritani se il buon Dio non avesse provveduto, nella sua imperscrutabile volontà, a produrre una quota di esseri deformi, malati, bisognosi di cure. Provocazione salutare: ancora oggi i treni per Lourdes convogliano, tra i benefattori, una quota consistente di soggetti privilegiati, alto- e medioborghesi, che vanno a sciacquare le loro anime al santuario.
L’umanitarismo psichiatrico, tra quelli ancora attivi nel nostro mondo, è in assoluto il più spregevole. Esso, infatti, drammatizza la sofferenza psichica al fine di speculare su di essa. Nella pratica psichiatrica corrente, è difficile dire dove finisce la buona fede e l’ignoranza e dove comincia il cinismo. Se anche si ammette che queste dimensioni si confondono, il risultato è lo stesso: industrie e psichiatri fanno quattrini, i pazienti ci rimettono la vita.
Giudizi del genere, che ho espresso più volte nei miei scritti, evocano sempre un certo scetticismo. Consultato da un mio paziente, un collega ha detto che io ho delle qualità, ma sono troppo ideologico. Lui, naturalmente, che fa diagnosi standardizzate e fittizie sulla base della bibbia del DSM è uno pragmatico.
Per introdurre il discorso sull’imperialismo psicofarmaceutico, riporto una vicenda esemplare.
M., figlia unica, è una bambina a cui la natura sembra aver donato tutte le qualità possibili: la bellezza, la sensibilità, l’intelligenza, una spiccata attitudine per lo studio e per la musica, ecc. Il suo tragitto evolutivo è eccellente: primeggia a scuola, coltiva interessi, studia musica. E’ il fiore all’occhiello della famiglia ed è portata in palma di mano dagli insegnanti, che prevedono per lei uno straordinario successo nella vita.
Certo, M. vive nel limbo degli introversi. Nonostante lo sviluppo adolescenziale la trasformi in una ragazza di inquietante bellezza, non manifesta che un vago interesse per i ragazzi e non si interessa delle frivolezze di cui si nutrono le compagne di classe.
Il problema, però, non è questo. Recependo le aspettative di un padre eccezionalmente dotato sotto il profilo intellettuale, che però non ha “sfondato”, M. ha imboccato fin da bambina il tunnel di un perfezionismo esasperato. Studia, molto più di quanto richiesto dagli insegnanti, con autentica passione, ma, via via che cresce, il mantenere il primato conseguito, e che nessuno minaccia, diventa un obbiettivo ansiogeno e ossessivo. Affamata di sapere e quasi inebriata dallo studio, M. non si dà alcun limite perché non si sente mai appagata.
A 18 anni la dedizione allo studio ha ormai un carattere manifestamente compulsivo. Cosa ci si può aspettare in una situazione del genere se non il sopravvenire di un opposizionismo regolativo? Di fatto, M. comincia ad avvertire, in prossimità dell’esame di maturità, una crescente stanchezza, a sperimentare qualche difficoltà di concentrazione, ad avere qualche amnesia.
L’esame viene superato a pieni voti, ma, quando intraprende lo studio universitario, M. repentinamente si blocca. Sta ore e ore sui libri, ma senza ritenere alcunché. Non comprendendo quello che sta accadendo e sentendosi in colpa, M. è frustrata, avvilita, depressa, angosciata.
Portata in visita da uno psichiatra, viene diagnosticata una depressione atipica (termine che implica il sospetto di una patologia sottostante più seria, psicotica) e prescritta una terapia con ansiolitici, antidepressivi e neurolettici. Dopo sei mesi, si è allo stesso punto per quanto riguarda il blocco nello studio: in più M. è inebetita e ingrassata. Si tratta, dunque, a detta dello psichiatra, di un disturbo dell’umore. Le terapie farmacologiche vengono incrementate.
Nel corso dei successivi 18 anni, M., la cui vita è finita prima di essere iniziata, tenta due volte il suicidio. L’alternativa alla disperazione è la maniacalità, che periodicamente si manifesta. M. non fa nulla di particolare nel corso degli episodi di eccitamento: canta, balla, si veste in maniera originale. Quanto basta a farla diventare la matta del paese.
La sua vita è vuota. Fiorisce, dunque, un delirio d’amore riferito ad un ragazzo che ha visto passare sotto la finestra.
La depressione atipica è divenuta prima un disturbo dell’umore monopolare, poi bipolare, infine una psicosi mista.
M vive imbottita di psicofarmaci, ai quali ormai si aggrappa. Nel tentativo di toglierle il delirio, lo psichiatra del CSM le inietta un neurolettico depôt ogni quindici giorni. Le prescrive inoltre un neurolettico per bocca, due equilibratori dell’umore, un antidepressivo, un ansiolitico, un induttore del sonno.
Cosa c’è di singolare in questa storia? Due aspetti.
Il primo riguarda la sintomatologia d’esordio. L’opposizionismo che, in alcuni studenti perfezionisti, interviene ad inibire la capacità di studio per porli al riparo da uno stress intollerabile non è un sintomo patologico, bensì un messaggio salutare dell’inconscio che, evidenziando uno squilibrio funzionale, dovrebbe essere decifrato per promuovere una ristrutturazione dell’esperienza più rispettosa dei limiti e dei bisogni umani.
Scambiarlo per l’indizio di un processo morboso è semplicemente un fatto di ignoranza. Se a questo si aggiunge il commento del primo psichiatra, che, di fronte alle fattezze adolescenziali di una ragazza introversa, ne ha segnalato la sostanziale immaturità, del tutto inconsapevole che essa avrebbe potuto insegnargli già molto di poesia, letteratura, filosofia, musica, il quadro è completo.
L’altro aspetto è che, dopo diciotto anni, la diagnosi scritta sulla cartella del CSM è del tutto falsa. In essa si parla solo di episodi depressivi, di rischio di suicidio, di eccitamento maniacale, di innesco delirante, di allucinazione, ecc.
Ritrovandosela davanti, nonostante il carico di psicofarmaci e la devastazione fisica legata all’aumento ponderale, significa scoprire un’anima ancora viva, sensibile, ricca di intuizione, culturalmente impegnata, creativa, ecc.
La storia esemplare di M. è uno scempio, frutto dell’ignoranza. La speculazione consiste nel fatto che essa consuma ogni mese circa 1500 euro di farmaci, dunque 18000 euro l’anno. Continuando su questa strada, pur considerando che le terapie psicofarmacologiche protratte tolgono una decina di anni di vita, essa, alla fine, avrebbe reso alle industrie qualcosa più di un milione di euro.
La malattia mentale, per l’industria, è una gallina dalle uova d’oro. Basta affrontare le crisi gravi giovanili solo con i farmaci, e il gioco è fatto: due pazienti su tre cronicizzato e diventano produttori di ricchezza.
2.
“Many low-income countries and civil society groups are crying out for help.”
Quest’affermazione, del tutto vera, ma patetica nel momento in cui si prende atto che essa è riferita ad una domanda di aiuto implicitamente espressa dai malati di mente del mondo in via di sviluppo, è la ragione essenziale di un’iniziativa della prestigiosa rivista medica britannica Lancet, la quale, in accordo con l’OMS, ha lanciato un nuovo movimento per la salute mondiale a livello mondiale che dovrebbe trovare il suo momento culminante in un summit nel 2009. Il lancio è avvenuto attraverso la pubblicazione di un voluminoso dossier (che riporto integralmente in appendice), dal quale è agevole ricavare alcuni punti di particolare interesse.
Il primo riguarda l’epidemiologia della malattia mentale:
"Ogni anno più del 30% della popolazione mondiale soffre di qualche forma di disordine mentale”.
Il secondo concerne la risposta terapeutica con la quale la malattia mentale è fronteggiata:
"Nonostante la grande attenzione che nei paesi occidentali si dedica alle opere della mente, alla filosofia come le arti, i disturbi mentali rimangono non solo dimenticati ma anche, nel profondo, stigmatizzati nelle nostre società".
“Due terzi [dei pazienti] non riceve alcun trattamento o le cure sono inadeguate, persino nei paesi che hanno maggiori risorse economiche".
Il terzo è, per l’appunto, un progetto umanitaristico di intervento su scala mondiale, che dovrebbe rispondere soprattutto alla domanda di cura dei malati di mente dei paesi in via di sviluppo, praticamente abbandontai a se stessi:
“Gran parte dei paesi africani e del SudEst asiatico spendono meno dell'1% del budget, già scarno, dedicato alla salute, per il settore dei disturbi mentali. E negli stessi paesi la media di psichiatri o infermieri specializzati è 200 volte meno che nei paesi più ricchi.”
“Basterebbero due dollari l'anno a persona per le cure di base della salute mentale nei paesi in via di sviluppo. Tre/quattro dollari a persona nei paesi di medio reddito. Quasi nulla rispetto ai finanziamenti che servono per altre patologie”. Questi pochi dollari basterebbero, secondo l'Oms, per i trattamenti primari di base nell'80 per cento dei più gravi disordini mentali e il 25-33% di quelli meno gravi.
Il quarto punto concerne la necessità di rimuovere, a livello culturale, lo stigma sociale che tuttora persiste nei confronti della malattia mentale:
"I mass media hanno una grande influenza sugli atteggiamenti della gente in relazione alla salute mentale. Purtroppo il messaggio che spesso arriva rinforza stereotipi negativi sui malati di mente: sono strani, imprevedibili e probabilmente pericolosi. Occorrono allora sforzi congiunti di professionisti dei media e di psicologi e psichiatri" .”
Il Dossier è ricco di analisi e spunti di grande interesse, soprattutto per quanto concerne l’incidenza sulla psicopatologia delle violente trasformazioni indotte dalla globalizzazione sulle culture locali e sull’organizzazione sociale e dei massicci fenomeni di immigrazione, che creano problemi di acculturazione.
Tra gli spunti di maggiore interesse segnalerei la distinzione, che raramente viene posta in evidenza, tra il carattere sociocentrico, vale a dire incentrato ancora sull’appartenenza e sul gruppo di parentela, che caratterizza le società in via di sviluppo, e il carattere egocentrico, vale a dire individualistico, che caratterizza quelle occidentali. L’inevitabile conflitto tra questi due aspetti è un’autentica chiave esplicativa del malessere psicologico che si sta diffondendo nei paesi in via di sviluppo, i quali, per accedere al mondo del benessere, non devono solo trasformare un’organizzazione produttiva vincolata all’agricoltura in un’organizzazione industriale. Il vero problema è che l’accettazione del modello capitalistico comporta una radicale trasformazione culturale del modo in cio l’individuo concepisce se stesso e il rapporto con il gruppo.
Il modello antropologico sotteso al capitalismo che, come ho detto altrove, è scientificamente infondato, concente di spiegare la diffusione epidemiologica del disagio psichico anche nelle società occidentali, laddove l’individuo si sente infinitamente solo e costretto a lottare per sopravvivere, vale a dire a rivaleggiare perpetuamente con gli altri, anche se ciò, in una quota non indifferente della popolazione, non significa scampare alla fame, ma mantenere ed accrescere un tenore di vita che va al di là dei bisogni primari.
Da quel modello, i paesi in via di sviluppo vengono letteralmente violentati sotto il profilo culturale. Ed è una violenza a vicolo cieco, dato che, in rapporto alla globalizzazione, l’aut-aut è tra il precipitare in una miseria infinita e l’accettarlo.
Il Dossier di Lancet è dunque ricco di spunti di interesse. Ciò nondimeno l’iniziativa che esso promuove è assolutamente inquietante.
3.
Poniamo tra parentesi il fatto che due dollari l’anno (cifra ben poco attendibile) moltiplicato per più di un miliardo di persone significa qualcosa come due miliardi di dollari.
Il vero problema, ovviamente, sta nel porre la questione della salute mentale sotto il profilo di un’urgenza medica. La sofferenza psicologica, nelle sue varie forme, è un dato reale, incontrovertibile e drammatico. Nel momento in cui, però, essa viene sussunta sotto la categoria della malattia mentale, nonostante nel dossier di Lancet sia più volte rilevata la multifattorialità del fenomeno, il primo intervento, che esaurirebbe rapidamente il budget, non può che essere psicofarmacologico. Sulla base di diagnosi operate sulla base del DSM-IV e di prescrizioni rivolte a curare una malattia medica (del cervello), l’ideologia neopsichiatrica potrebbe colonizzare il mondo intero.
Si realizzerebbe, mutatis mutandis, lo stesso fenomeno legato all’epoca della colonializzazione, allorché la civiltà bianca esportò nei paesi del Terzo Mondo il modello manicomiale, ad esso del tutto estraneo, che ha attecchito ed è ancora in funzione.
La diffusione mondiale del modello neopsichiatrico sull’onda della globalizzazione sarebbe un bel paradosso. Essa, infatti, se si pongono tra parentesi la schizofrenia e la psicosi maniaco-depressiva, le cui percentuali (rispettivamente intorno all’1% e all’1,5%) sono costanti nel tempo e nello spazio, è una clamorosa smentita di quel modello. L’influenza dei fattori ambientali è inconfutabilmente attestata sia dal parallelismo inverso tra PIL e Indice della Salute Sociale che si realizza in tutti i paesi che aderiscono al modello capitalistico e si avviano verso la sua realizzazione, sia dalle patologie che investono gli immigrati sradicati dal loro ambiente originario e dalla loro cultura (e che si riflettono anche nella crescita di vissuti nasiosi e persecutori negli indigeni occidentali…).
Certo, alla clamorosa smentita offerta dai dati epidemiologici, la neopsichiatria può sempre opporre il suo cavallo di battaglia: la capacità individuale di adattarsi allo stress. Se, dati i cambiamenti che intervengono quando un paese imbocca la via dell’industrializzazione, alcuni ammalano e altri riescono ad addattarsi, ciò significa che i primi sono geneticamente vulnerabili, in qualche misura difettosi.
Adottare questa logica, però, in rapporto ad un fenomeno che, ormai interessa, un quarto della popolazione mondiale, sembra veramente ridicolo.
Nel produrre l’uomo, la natura non ha previsto che dovesse cimentarsi con le aspre e inique leggi del capitalismo e con il tipo di organizzazione sociale atomizzata che esso produce. A modo suo, attraverso la sofferenza psichica, la natura rivendica i suoi diritti.
In breve, quello che sta avvenendo a livello mondiale pone in luce un conflitto tra natura umana e modello di sviluppo socio-economico occidentale, al quale è sottesa una cultura – quella individualistica e egoistica – che incide e devasta tutte le culture che ancora riconoscono il legame sociale e l’appartenenza come dimensioni primarie dell’esistenza.
Fronteggiare questa emergenza con gli psicofarmaci può essere un obbiettivo esaltante per le industrie (gran parte delle quali a capitale occidentale), ma, ai fini dell’umanità, mediocre e fuorviante.
Riguardo al problema della malattia mentale, la necessità non è quella di un allarme (peraltro giustificato) che sensibilizzi i governi nazionali ad investire somme maggiori di denaro nell’erogazione degli psicofarmaci, bensì quella di una rivoluzione paradigmatica che sormonti il riferimento alla psichiatria come branca specialistica della medicina e la conduca sul terreno suo proprio di scienza interdisciplinare. Occorre in breve una panantropologia, al cui interno la sofferenza psichica possa essere compresa e spiegata.
4.
Nonostante le apparanze, dunque, l’iniziativa di Lancet rientra a pieno titolo nell’umanitarismo ipocrita che, in questi ultimi decenni, ha rappresentato l’arma vincente della neopsichiatria. L’umanitarismo si riconduce al fare riferimento ad un grido di dolore che si leva dall’universo della sofferenza psichica cui occorre dare una risposta. L’ipocrisia sta nel fatto che l’urgenza, nell’aspettativa che maturino servizi pubblici assistenziali capaci di farsi carico di quella sofferenza in un’ottica multidimensionale, non può essere affrontata che utilizzando l’arma più immediata ed economica: gli psicofarmaci.
Ho già scritto più volte che gli psicofarmaci non vanno demonizzati. In alcuni casi il loro uso non solo è lecito, ma necessario. Il problema ovviamente verte sul significato che si accorda alle cure psicofarmacologiche, e in particolare al loro potere sintomatico o terapeutico. In medicina questa differenza è riconosciuta da sempre: un farmaco antinfluenzale allevia i sintomi, ma non incide sull’attività del virus; un antibiotico, viceversa, cura la malattia perché debella l’attività di un batterio da esso sensibile.
La neopsichiatria sostiene che gli psicofarmaci hanno un potere terapeutico. Ciò però implica che i sintomi psichiatrici siano l’espressione di un disturbo del cervello che può essere rivelato dalle circostanze ambientali, ma la cui causa prima è la predisposizione genetica, vale a dire una vulnerabilità costituzionale in conseguenza della quale un determinato cervello risponde a quelle circostanze con modalità disfunzionali rispetto ad altri soggetti che si confrontano con esse. Se si ammette però una predisposizione genetica alla base di ogni disagio psichico, ciò significa che l’individuo ha una malattia cronica – in breve, è difettoso – che può riconoscere fasi di latenza, ma non può guarire mai del tutto. Su questa base il trattamento farmacologico può, al di là delle fasi acute, ridursi ad un dosaggio di mantenimento, ma va proseguito per tutta la vita.
Se, viceversa, si ritiene che gli psicofarmaci hanno un significato meramente sintomatico, vale a dire che sono in grado solo di contenere e alleviare i sintomi, l’impostazione terapeutica cambia radicalmente. Intanto, infatti, il loro uso è prescritto solo in caso di necessità, vale a dire quando l’individuo è squilibrato dall’attività di conflitti psicodinamici di cui non è consapevole e le cui conseguenza non è in grado di tollerare.
In secondo luogo, quell’uso è subordinato al principio di prescrivere il dosaggio minimo indispensabile a realizzare un contenimento dei sintomi. La pratica del dosaggio minimo non può prescindere dalla collaborazione del soggetto, che sperimenta soggettivamente i sintomi. Ciò significa partire da un dosaggio piuttosto basso e aggiustarlo in rapporto agli effetti sperimentati dal soggetto, che può giungere all’autogestione.
In terzo luogo, la terapia farmacologica va periodicamente scalata per verificare la capacità acquisita dal soggetto, attraverso la psicoterapia, di amministrare con nuovi strumenti il suo mondo interiore.
L’attribuire agli psicofarmaci un potere sintomatico significa identificare nel disagio psichico l’espressione di un conflitto potenzialmente evolutivo la cui soluzione richiede un diverso modo di porsi del soggetto in rapporto a se stesso e in rapporto al mondo. Tale modo richiede un tragitto terapeutico che il soggetto non è in grado di intraprendere e di portare a termine da solo. Un tragitto terapeutico che diventa significativo solo quando esso si realizza sotto forma di un salto di qualità culturale nella conoscenza che l’uomo ha di se stesso e del suo rapporto con l’ambiente.
E’ evidente che l’estensione di un progetto del genere a livello mondiale è, nell’immediato, irrealizzabile e, se si vuole, più ridicola del progetto di inondare il pianeta di psicofarmaci.
Occorrerebbe, però, tenerne conto perché esso implica che la sofferenza psichica è il sintomo di una disfunzione che non potrà essere sormontata se non in virtù di una nuova antropologia, che consenta alle società di capire i diversi tragitti che esse hanno realizzato e, riconosciutine i limiti, imboccare un nuovo tragitto.
Se non è più tempo di affermare che il capitalismo è schizofrenogeno, non si può non ritenere, in conseguenza della sua estensione a livello mondiale, che esso induce comunque una scissione nel patrimonio dei bisogni umani di appartenenza e di individuazione le cui conseguenze sono terribili: per i “normali” che si adattano ad esso sacrificando l’empatia e per coloro che non riescono ad adattarsi.
Appendice
Lancet (settembre 2007)
The Lancet Series on Global Mental Health: Article Collection
Launching a new movement for mental health
“Despite the great attention western countries pay to the mind and human consciousness in philosophy and the arts, disturbances of mental health remain not only neglected but also deeply stigmatised across our societies.”
These are the introductory words of The Lancet's editor Dr Richard Horton, in a comment to introduce the series. He says: “For the most part, these organisations have done far too little, if anything at all? In the past, The Lancet has tried to draw attention to mental health services in particular countries. With a series of papers today from an internationally diverse Lancet Global Mental Health Group, to whom we owe a deep debt of thanks, together with a call to action and a commitment to track and monitor progress across arrange of mental health indicators in the run up to a global summit on mental health in 2009, we aim to change this culture of lost opportunity.”
14% of global disease burden due to mental disorders
An estimated 14% of the global burden of disease is due to neuropsychiatric disorders (NPDs). NPDs are the most important contributors to morbidity among the non-communicable diseases (NCDs)—more than heart disease, stroke and cancer—mainly due to the chronically disabling nature of depression, alcohol- and substance-use disorders, and psychoses. However, their true burden is likely to be underestimated because of inadequate appreciation of the connection between mental disorders and other health conditions.
In the first of a series of six reviews, titled “No health without mental health”, Professor Martin Prince, Institute of Psychiatry, King's College London, UK, and colleagues provide evidence that mental illnesses increase the risk for developing many physical illnesses.
Huge increase in resources for mental health disorders required worldwide
Scarcity of resources for mental health, inequity in access, and inefficiencies in their use have serious consequences, the most direct of which is that people who need care get none. In this second paper, titled “Resources for mental health”, Dr Shekhar Saxena, World Health Organisation, Geneva, Switzerland, and colleagues say that, especially in low and middle-income countries, government spending on mental health is far lower than what is needed. Almost a third of countries worldwide do not have a specified budget for mental health and one-fifth of those that have, spend less than 1% of their budget on mental health.
Treating and preventing mental disorders in low-income and middle-income countries
Depression can be treated effectively in low- and middle-income countries with low-cost antidepressants or psychological interventions such as interpersonal therapy, conclude Professor Vikram Patel, London School of Hygiene and Tropical Medicine, UK, and colleagues, authors of the third paper in The Lancet's Global Mental Health Series. The authors say that such interventions, when delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS.
They add that brief interventions, delivered by primary care professionals, are effective for the management of hazardous alcohol use and that low-cost antipsychotic drugs and family focused psychosocial interventions are effective for the management of schizophrenia.
Mental health systems in countries: where are we now?
More than 85% of the world's population lives in 153 low- and middle-income countries (LAMICs), with most of these countries allocating very scarce financial resources and grossly inadequate manpower and infrastructure for mental health. In the fourth paper of the series, Dr K S Jacob, Department of Psychiatry, Christian Medical College, Vellore, India, and colleagues conclude: “Innovative approaches are needed to promote the reality of mental disorders and efficiently use available resources to ensure that basic mental health care reaches all individuals.”
The authors say that many LAMICs lack mental health policy and legislation (around a third of WHO's 191 member-countries have no mental health laws), and this deficiency stops them directing their mental-health programmes and services.
Overcoming barriers to improve mental health services in low- and middle-income countries
Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle income countries. In the fifth paper of the series, Dr Benedetto Saraceno, Director, Department of Mental Health and Substance Abuse, WHO, Geneva, Switzerland, and colleagues conclude: “Many of the barriers to progress in scaling-up of mental health services can be overcome by the generation of political will for the organisation of accessible and humane mental-health care.”
They add that advocates for mental health provision (which includes those with mental-health disorders and their families) need to come together to deliver clear, strong messages about what is required.
A call for action
Every year up to 30% of the population worldwide will suffer from some form of mental disorder, and at least two-thirds of those receive inadequate or no treatment, even in countries with the best resources. The treatment 'gap' approaches 90% in many developing countries. In this final paper of six in The Lancet Global Mental Health Series, The Lancet Global Mental Health Group join together to call for a scale-up of mental health services worldwide.
The cost of providing services at the necessary scale is estimated at US$2 per person in low-income countries and US$3-4 per person in middle-income countries, which is modest compared with the costs of scaling up services for other major contributors to the global-disease burden.
Lancet (ottobre 2007)
Launching a new movement for mental health
Despite the great attention western countries pay to the mind and human consciousness in philosophy and the arts, disturbances of mental health remain not only neglected but also deeply stigmatised across our societies. Viewed through a global lens, this marginalisation is only amplified still further. Yet the fragile—and utterly fragmented for the most disadvantaged—state of mental health services in many countries is not for the want of trying.
In 2001, for example, WHO devoted its World Health Report to mental health, with the optimistic message “new understanding, new hope”. Gro Harlem Brundtland wrote: “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.”1 As Director-General, she set a deservedly high standard for WHO and others to follow and be judged by.
Since then, WHO has continued to publish reports on mental health.2 But somehow the agency, through its leadership and partnerships, has been unable to convert fine words into tangible actions at country level. Partly this is because WHO has not backed its words with resources. And partly it is because WHO’s leadership has failed to build a sustainable mechanism across global and country institutions to hold itself and others accountable for its recommendations. This paralysis is surprising. Many low-income countries and civil society groups are crying out for help.
WHO is not the only institution with a responsibility to strengthen mental health services. The World Bank, country donors (such as the USA, UK, and European Union), foundations (such as the Gates and Rockefeller Foundations), research funding bodies (eg, the US National Institutes of Health), and professional associations all share a duty to make mental health a central theme of their strategies and financial flows. For the most part, these organisations have done far too little, if anything at all. In the past, The Lancet has tried to draw attention to mental health services in particular countries.3,4 With a Series of papers launched today from an internationally diverse Lancet Global Mental Health Group, to whom we owe a deep debt of thanks, together with a call to action and a commitment to track and monitor progress across a range of mental health indicators in the run up to a global summit on mental health in 2009, we aim to change this culture of lost opportunity.
The key messages from our Series are clear. First, mental health is a neglected aspect of human well-being, which is intimately connected with many other conditions of global health importance. Second, resources for mental health are inadequate, insufficient, and inequitably distributed. Third, there is already a strong evidence base on which to scale up mental health services. Fourth, most low-income and middle-income countries currently devote far too few resources to mental health. Fifth, there are critical lessons to learn from past successes and failures—for political leadership and priority setting, for increasing financial support, for decentralising mental health services, for integrating mental health into primary care, for increasing health workers trained in mental health, and for strengthening public health perspectives in mental health. Finally, any call to action demands a clear set of indicators to measure progress at country level.
During the next 2 years, The Lancet will make mental health one of its campaign focal points. We urge partners to join the broad new social movement we are launching to strengthen mental health.
Richard Horton
The Lancet, London NW1 7BY, UK
1 WHO. World health report. Mental health: new understanding, new hope. 2001. http://www.who.int/whr/2001/en (accessed Aug 20, 2007).
2 Herrman H, Saxena S, Moodie R, eds. Promoting mental health: concepts, emerging evidence, practice. 2005. http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf (accessed Aug 20, 2007).
3 The Lancet. Mental health: neglected in the UK. Lancet 2007; 370: 104.
4 Butcher J, Samarasekera U, Wilkinson E, Shetty P. Special report. Lancet 2007; 370: 117–24.
Stigma and mental health
The stigma attached to mental illness is the main obstacle to the provision of care for people with this disorder. Stigma does not stop at illness: it marks those who are ill, their families across generations, institutions that provide treatment, psychotropic drugs, and mental health workers. Stigma makes community and health decision-makers see people with mental illness with low regard, resulting in reluctance to invest resources into mental health care. Furthermore, stigma leads to discrimination in the provision of services for physical illness in those who are mentally ill,1 and to low use of diagnostic procedures when they have physical illness.2
Stigma of mental illness can be defined as the negative attitude (based on prejudice and misinformation) that is triggered by a marker of illness—eg, odd behaviour or mention of psychiatric treatment in a person’s curriculum vitae. The presence of stigma starts a vicious circle that leads to discrimination in all walks of life,3 decreasing self-esteem and self-confidence (resulting at least partly from the experience of a person with mental illness), a low treatment effect or high probability of relapse for those in remission, and thus to a reinforcement of the negative attitudes and discrimination.4 This model of the vicious circle4 suggests that there can be various strategies for those who wish to fight stigma. We can think of ways of reducing the visibility of markers (eg, by provision of treatment that is not associated with extrapyramidal side-effects), ways of reducing discrimination, interventions that will help raise the self-esteem of people with mental illness, education of families, and more investment in treatment that rapidly reduces the severity of illness or that prevents relapses.
Many people contribute to the development and re-inforcement of stigma. Health-care workers commonly use words that are stigmatising—eg, speaking of schizo-phrenics, or use of pejorative terms for mental illness instead of speaking of the person who has the illness. Medical personnel may refuse to treat physical illness or injury in those with mental illness. Psychiatrists and mental health personnel are no exception in this general unawareness of how their behaviour contributes to stigma.5 People who have mental illness and who have lost much of their self-confidence over time contribute to the image of the person with mental illness who does not try to contribute to their health and sustenance. Govern-ments make statements or take action that reinforce prejudice—eg, by proposing sterilisation of people with mental illness or retardation without their consent, or by avoiding parity in reimbursement for treatment of mental illness.
However, there is good news. The global programme against stigma and discrimination because of schizophrenia4 was successfully implemented in more than 20 countries worldwide. Furthermore, local initiatives have successfully removed or reduced stigma. The Euro-pean Union’s recent consultation about mental health promotion identified the fight against stigma as an important area of work for European countries.6 WHO has highlighted the need to combat stigma and to foresee appropriate measures in national mental health policies.7
Moreover, experience over the past two decades has identified the main parts of successful action against stigma. These are: consultation of people with mental illness and their families about targets for action against stigma and their involvement in relevant programmes; conception of the fight against stigma as a long-term endeavour that is incorporated into health and other social services; involvement of all stakeholders in the programme, including government, health-service personnel, and the media; and a focus on specific problems that result from stigma (eg, discrimination against people with mental illness) rather than generic approaches to change people’s attitudes.
Stigma attached to mental illness is the main obstacle to the success of programmes to improve mental health. It is fortunate that determined action can remove stigma, to a large extent.
Norman Sartorius
Association for the Improvement of Mental Health Programmes, 1209 Geneva, Switzerland
sartorius@normansartorius.com
I declare that I have no conflict of interest.
1 Fang H, Rizzo JA. Do psychiatrists have less access to medical services for their patients? J Ment Health Policy Econ 2007; 10: 63–71.
2 Lawrence D, Coghlan R. Health inequalities and the health needs of people with mental illness. NSW Public Health Bull 2002; 13: 155–58.
3 Thornicroft G. Shunned. Oxford: Oxford University Press, 2007.
4 Sartorius N, Schulze H. Reducing the stigma of mental illness. Cambridge: Cambridge University Press, 2005.
5 Sartorius N. Iatrogenic stigma of mental illness. BMJ 2002; 324: 1470–71.
6 Wahlbeck K, Jane-Llopis E, Katschnig H. The health policy of the European Union in the field of mental health. Psychiatrie (in press).
7 WHO: World health report. Mental health: new understanding, new hope. 2001. http://www.who.int/whr/2001/en (accessed July 20, 2007).
Promotion of mental health in poorly resourced countries
The call for action on treatment and prevention of mental disorders1 needs to be matched by a call to integrate mental health into public-health action, otherwise it will send incomplete messages to professionals, ministries, and donors. The connections between mental health and other aspects of health and productivity make mental health promotion in low-income countries a necessity—far from the luxury it is often portrayed as.
Public health is the organised worldwide and local effort to promote and protect the health of populations and reduce health inequities.2 Mental health is intrinsic to health and linked to behaviour, as shown by the several connections between mental disorders and other conditions.3
Mental health is a set of positive attributes in a person or a community. WHO describes it as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.4 Poor mental health is associated with social disadvantage, human-rights abuses, and poor health and productivity, as well as increased risk of mental disorders.5 Promoting and satisfying mental health needs optimally involves fulfilling several other requirements—eg, interventions to assist low-income women with breastfeeding will simultaneously address infant-nutrition needs.6 Conversely, human-rights abuses, conflict, and emergencies associated with wars and civil unrest are associated with poor mental health outcomes and poor physical health and social conditions.7
Mental health is promoted through population-based public-health measures, alongside health-system change.8 Notions that are fundamental to public health are crucial to the improvement of mental health—eg, the causes of individual differences in health status might not be the same as the causes of differences between populations.9 Evidence is emerging for the effectiveness of mental health promotion in public health.4,10 However, services, governments, and non-governmental organisations tend to concentrate solely on the neglected needs of people with established illnesses and disabilities. The health-promotion strategies of advocacy, communication, policy and legislative changes, community participation, and research and assessment can promote mental health together with physical health and productivity.4
Activities to promote mental health take place at several levels. Some are distant from the individual, such as policies to tax alcohol products, whereas others are closer to the individual, such as home-visiting health-promotion programmes.8 Effective interventions across the lifespan include support for parents of infants, school-based inter-ventions, workplace and unemployment programmes for adults, and activity programmes for elderly people. Working to achieve occupational justice—the extent to which all individuals have access to participation in a range of fulfilling tasks—is an example of such an intervention.11 We need to understand more about the potential value of mental health promotion of everyday activities and use this understanding to develop and assess promotion initiatives.
Tackling important social and health issues, such as prevention of HIV infection, maternal and child health, violence at home and in the streets, substance abuse, and gender equity, needs interventions that focus on developing assertiveness and self-reliance and appropriate participation, which are in turn components of mental health. For instance, mental health promotion is being used and assessed as a deliberate strategy for prevention of HIV infection.12
The evidence for practice and policy needs strength-ening worldwide, especially in low-income countries and areas affected by conflict where the need is greatest. Changes in mental health status with health and social interventions need to be measured and monitored. The call for action1 notes that mental disorders have an effect on several outcomes, ultimately affecting the development potential of society. Equally important are the opportunity costs of poor mental health, and research and evaluation to support ways to avoid these costs.
The actions needed in all countries include research and assessment of public mental health interventions, development and monitoring of indicators of population mental health, and advocacy to make public-health pro-fessionals, politicians, and government officials in all social sectors aware of the effectiveness of acting at a population and non-health sector level to promote mental health. Mental health concerns everyone and is not the preserve of health professionals and the health services. These actions are vital, alongside treatment and prevention of mental illness, for improved population mental health, and hence social and economic development in countries.
*Helen Herrman, Leslie Swartz
Department of Psychiatry and School of Population Health, University of Melbourne, Carlton, Victoria 3101, Australia (HH); and University of Stellenbosch, Stellenbosch, South Africa (LS)
h.herrman@unimelb.edu.au
We declare that we have no conflict of interest.
1 Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet 2007; published online Sept 4. DOI:10.1016/S0140-6736(07)61242-2.
2 Beaglehole R. Global public health: a new era. Oxford: Oxford University Press, 2003.
3 Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet 2007; published online Sept 4. DOI:10.1016/S0140-6736(07)61238-0.
4 Herrman H, Saxena S, Moodie R, eds. Promoting mental health: concepts, emerging evidence and practice. 2005. http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf (accessed Aug 20, 2007).
5 Desjarlais R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. New York: Oxford University Press, 1995.
6 Max-Neef MA. Human scale development: conception, application and further reflections. London: Apex Press, 1991.
7 Mollica RF, Cardozo B, Osofsky H, Raphael B, Ager A, Salama P. Mental health in complex emergencies. Lancet 2004; 364: 2058–67.
8 Sartorius N. Universal strategies for the prevention of mental illness and the promotion of mental health. In: Jenkins R, Ustun TB, eds. Preventing mental illness: mental health promotion in primary care. Chichester: John Wiley & Sons; 1998: 61–67.
9 Rose G. The strategy of preventive medicine. Oxford: Oxford University Press, 1992.
10 Jane-Llopis E, Barry M, Hosman C, Patel V. Mental health promotion works: a review. Promot Educ 2005; suppl 2: 9–25.
11 Wilcock AA, Townsend T. Occupational therapy terminology: interactive dialogue. J Occup Sci 2000; 7: 84–86.
12 Devine A, Kermode M, Chandra P, Herrman H. A participatory intervention to improve the mental health of widows of injecting drug users in north-east India as a strategy for HIV prevention. BMC Int Health Hum Rights 2007; 7: 3.
Psychologist gives advice and counselling on weekly radio programme in Banda Aceh, northern Summatra
Mental health and human rights
The Lancet Series on global mental health draws attention to a long neglected health and social policy issue. This concern is particularly needed today, because social conditions, especially widespread poverty, disasters, violence, and war, can precipitate the breakdown of vulnerable individuals and social systems.
In this context we note how groups such as the People’s Health Movement (PHM), a coalition of several groups working in many countries, have evolved an approach to mental health that is qualitatively different from expert-driven strategies. This approach is exemplified by the Peoples Charter for Health1 and subsequent documents2 based on peoples’ experiences and aspirations.3 Just as people living with HIV/AIDS have provided input into policy and practice, there is a need to give a greater centrality to those living with mental illness. Such an opportunity is afforded by the UN Convention on the Rights of Persons with Disabilities, which has had the active participation of individuals with disabilities, including those living with mental illness.
The right to life and liberty is primary in human rights discourse. However, for people with mental illness, deprivation of liberty by forced institutionalisation might be justified on grounds of danger to themselves and others. This justification does not take into account the people who have died or been permanently scarred by loss of liberty or basic human dignity. User-survivors narrate the experience graphically, and seek a total embargo on forced interventions.4 The UN Convention recognises that all people have rights to both life and liberty and to physical and mental integrity. However, it neither expressly bans nor explicitly permits forced intervention. This stalemate affords an opportunity to revisit forced interventions from the standpoint of people with mental illness.5
Scholars have argued that personal effectance (the opportunity to act or function) is essential for human beings to fulfil their potential.6 The right of all individuals to be recognised in law as having the capacity to act promotes such personal effectance; however, the capacity to act has been regarded as questionable for people with mental illness. Consequently, there is legal provision to enable arrangements that protect the interests of such people, although such arrangements have been viewed as legal reinforcement of social stigma.7 The UN Convention on the Rights of Persons with Disabilities has further questioned this process of disqualification. Article 12 of the Convention recognises the full legal capacity of all people with disability, and that the capacity to act is an integral component of this legal capacity. Yet the article does not negate the need for support—instead, in acceptance of human interdependence, the Convention recognises the right to seek support, and in acceptance of human frailty, it establishes the standards for providing support and safeguards against abuse. The mechanisms of support for people with mental illness need not be based on the all-or-nothing theory of guardianship. The personal ombudsperson system in Sweden8 and the restricted guardianship procedures of India9 are steps in that direction.10
People living with mental illness have always faced difficulties in participating in society because of pressure to conform to normal social and legal standards. This pressure has been eased by the Convention, which accepts the principle of reasonable accommodation and allows the norms to be modified to accommodate people’s diversity. The Convention also recognises that people with disabilities, including those living with mental illness, have a right to be consulted in the formulation of all policies, laws, and practices that affect them. There is thus a duty to recast psychiatric practice and procedure in active consultation with its users.
In addition to medical interventions, an important demand being voiced by civil society representatives is for the creation of support networks for human distress and illness that are wider than the medical establishment.11 A cue could be taken from innovative community-based work by non-governmental organisations and professional groups. The groups include: BasicNeeds, 12 working in several countries; CBR Forum (community-based rehabilitation), partnered with 90 organisations across India; and the Women’s Health Empowerment Programme, supported by WHO. Various creative strat-egies have evolved, such as: the setting up of self-help groups, including people with mental illness and their support networks; addressing issues of livelihood; pro-motion of life-skills education and parenting skills; and studying and using local healing traditions, including spiritual traditions.13 These methods, combined with the psychiatric care offered by the medical establishment, could make for a mental health policy that is holistic and consonant with human rights.
The UN Convention on the Rights of Persons with Disabilities and the People’s Movement for Mental Health require that the stereotypes of mental health law and policy be revisited. Because law and policy do not exist in isolation from society, this is a mandate to re-examine their implications for social interactions, in therapy, and in clinical decision-making.
Amita Dhanda, *Thelma Narayan
National Academy of Legal Studies and Research, Hyderabad, Hyderabad, India (AD); Community Health Cell, Bangalore, Karnataka 560034, India (TN)
thelma@sochara.org
We declare that we have no conflict of interest.
1 People’s Health Movement. People’s Charter for Health. http://www.phmovement.org/pdf/charter/phm-pch-english.pdf (accessed Aug 15, 2007).
2 People’s Health Movement. Mumbai Declaration from the III International Forum for the Defence of People’s Health. http://www.phmovement.org/files/md-english.pdf (accessed Aug 15, 2007).
3 People’s Health Movement. http://www.phmovement.org (accessed July 6, 2007).
4 WNUSP and Bapu Trust, Pune. First person stories on forced interventions and being deprived of legal capacity. http://psychrights.org/Stories/stories.pdf (accessed Aug 17, 2006).
5 Minkowitz T. United Nations convention on the rights of persons with disabilities and the right to be free from non consensual psychiatric interventions. Syracuse J Intl Law Commerce 2007; 34: 405.
6 Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychologist 2000; 55: 68–78.
7 Dhanda A. Legal order and mental disorder. New Delhi: Sage Publications, 2000.
8 PO-SkŒne. http://www.po-skane.org (accessed July 10, 2007).
9 Dhanda A. Legal capacity in the disability rights convention: stranglehold of the past or lodestar for the future. Syracuse J Intl Law Commerce 2007; 34: 429.
10 Nussbaum M. Frontiers of justice: disability, nationality, species membership. Cambridge, MA: Belknap Press, 2006.
11 Department of Health and Family Welfare. Priorities for mental health sector in Gujarat India. Gujerat: Government of Gujarat, 2003.
12 Basic Needs Review. Community my community. Sri Lanka: Basic Needs, 2005.
13 Centre for Advocacy in Mental Health. Alternative mental health—report of a workshop, Aug 27–29, 2003. 2003. http://www.camhindia.org/amh_workshop_report.html (accessed Aug 20, 2007).
Mental health and global movement of people
Migration is a key part of globalisation,1 and the social, cultural, economic, and political forces of globalisation have substantially changed the determinants and consequences of migration. 170 million people live outside their country of origin, and every year more than 700 million people cross national boundaries.2 The public-health importance of this massive movement of people is apparent for communicable diseases, and, although less visible, is no less important for mental health.
Although globalisation promises universal economic and social benefits, it leads to increased marginalisation, unemployment, erosion of job security, increased poverty, reduced access to health care and education, and reduced social provision for people who are ill or unemployed. Many factors that lead to permanent and temporary migration are products of globalisation, and are determinants of mental health and illness.3,4 Rapidly emerging market economies need cheap labour, which might involve women from rural areas with poor education who have been separated from their family and who have access to few legal protections. High-income countries (ie, those in Europe, North America, and Australia and New Zealand) with declining and ageing populations need immigrants, but are often ambivalent about them when they come. Complex emergencies and human-rights abuses produce large flows of asylum seekers and refugees, mostly into neighbouring low-income countries that have little capacity to receive and to care for them. Poverty fuels the deadly trade of people-trafficking, and is the major engine for undocumented immigration. The decline of rural economies everywhere and rapidly escalating global ecological problems will substantially increase the pressure on people to move.
The encounter between people and cultures is mediated by a global flow of commodities,5 information, and, increasingly, direct contact between people. Most migration occurs from poor, generally sociocentric (ie, collectivist) cultures to those that are richer and egocentric (ie, individualist).4 Acculturation, which occurs when different cultural groups are in sustained contact with one another,6 might lead to distress and dysfunction in some individuals and to tension between cultural groups. The power of institutional or individual racism over the mental health of immigrants must not be ignored. Fragmentation and erosion of identity, the loss associated with displacement from familiar contexts and support networks, the difficulties of settlement, and the pressures on accustomed family structures and relationships can increase vulnerability to mental illness.7
Sociocentric individuals who migrate from socio-centric societies to those that are egocentric are likely to develop distress—especially if they do not have access to a community of people with similar backgrounds.8 An additional source of stress on immigrants is that host societies have generally failed to respond effectively to the reality of ethnic, cultural, and linguistic diversity.9 Pilot programmes that show effective delivery of a mental health programme to immigrants who are in the minority have little effect on mainstream mental health services.10
The effect of movement of trained and professional individuals and their families around the world cannot be underestimated. The cost of training a doctor or an engineer in a low-income country may be proportionately low, but the brain drain can cost millions of dollars, especially in countries that can ill afford to lose such skills. Therefore the treatment gap in low-income countries will probably widen, and there have been recent calls for developed countries to refund donor countries.11 The money that migrants send back to their country of origin may compensate, but this is not the full story. The mental health of people who are left behind and who have poor resources, the potential resulting resentment, and the role of acculturation on the health of migrants need urgent wider discussion.
*Dinesh Bhugra, Iraklis Harry Minas
Section of Cultural Psychiatry, Institute of Psychiatry, King’s College London, London SE5 8AF, UK (DB); and Centre for International Mental Health, School of Population Health, University of Melbourne, VIC, Australia (IHM)
d.bhugra@iop.kcl.ac.uk
We declare that we have no conflict of interest.
1 Mignolo W. Globalization, civilization processes and the relocation of language and cultures. In: Jameson F, Miyashi M, eds. The cultures of globalization. Durham, NC: Duke University Press, 2001: 32–53.
2 Koehn P. Globalization, migration health, and educational preparation for transnational medical encounters. Global Health 2006; 2: 2.
3 Minas H. Migration, equity and health. In: McKee M, Garner P, Stott R, eds. International co-operation in health. Oxford: Oxford University Press, 2001: 151–74.
4 International Organization for Migration. World migration 2005: costs and benefits of international migration. Geneva: International Organization for Migration, 2005.
5 Inda J, Rosaldo R. Roving commodities. In: Inda J, Rosaldo R, eds. The anthropology of globalization. Oxford: Blackwell Publishing, 2001: 231.
6 Berry J. Acculturation and identity. In: Bhugra D, Bhui K, eds. Textbook of cultural psychiatry. Cambridge: Cambridge University Press (in press).
7 Bhugra D. Migration and mental health. Acta Psychiatr Scand 2004; 109: 243–58.
8 Bhugra D. Cultural identities and cultural congruency: a new model for evaluating mental distress in immigrants. Acta Psychiatr Scand 2005; 111: 84–93.
9 Minas H. Developing mental health services for multicultural societies. In: Bhugra D, Bhui K, eds. Textbook of cultural psychiatry. Cambridge: Cambridge University Press (in press).
10 Fernando S. Multicultural mental health services: projects for minority ethnic communities in England. Transcult Psychiatry 2005; 42: 420–36.
11 Patel V, Boardman J, Prince M, Bhugra D. Returning the debt: how rich countries can invest in mental health capacity in developing countries. World Psychiatry 2006; 5: 67–70.
Nurses and mental health services in developing countries
Some of the barriers to progress identified in this Lancet Global Mental Health Series concern challenges in the implementation of mental health care in primary care settings in low-income and middle-income countries, and the few professionals who are appropriately trained and supervised in mental health care. We believe that training, employing, and adequately supporting nurses is a readily achievable solution for improving mental health services in these countries. According to the 2006 World Health Report1 there are more nurses than any other category of health-care provider; the International Council of Nurses (ICN) estimates that there are more than 13 million nurses worldwide. Furthermore, nurses provide almost all primary health care in most low-income and middle-income countries. However, most nurses do not have the expertise to assess and treat mental health disorders.2 Often nurses’ ability to function in a wide scope of practice, including prescriptive authority, is limited by outdated practice acts that are not aligned to the mental health needs of populations.1
A recently completed survey of nurses and mental health in countries around the world, done by WHO and the ICN, confirms that, in many low-income and middle-income countries, nurses provide most mental health services.3 However, many nurses have no mental health training and few have had training experience in a community mental health setting (in which most mental health services should be provided).
Analysis of the 178 completed questionnaires (from WHO member states and other entities representing 98% of the world population) showed substantial variations across countries with different income levels. For example, there are over 100 times more nurses per head in mental health settings in high-income countries than in low-income countries; there are over 66 more nurses trained in mental health per head in high-income countries than in low-income countries. Moreover, the level of training of mental health nurses is usually less in low-income countries than in high-income countries. There are fewer community mental health facilities in low-income and middle-income countries than in high-income countries. These deficiencies make provision of mental health community services very difficult for low-income and middle-income countries.
Nurses have more authority to prescribe and continue drug prescriptions in countries in Africa, southeast Asia, and the western Pacific than they do in other regions. This difference could be attributable to recognition of the need to make psychoactive drugs more available in countries where other mental health services are scarce.3
Comments in response to the open-ended questions in the survey3 suggest that an overall nursing shortage contributes to insufficient numbers of nurses in mental health care. Respondents say that this shortage is even more acute for nurses in this sector because of the few incentives for nurses to be trained to provide specialised services. There are few financial incentives for nurses either to receive mental health training or to provide mental health services. The stigma of mental illness also contributes to this problem by limiting the number of nurses willing to make mental health nursing a career.
Nurses are a crucial component in almost every health-care system worldwide. They will need to be involved in any attempt to reduce the huge burden of disease for mental disorders. As the WHO and ICN report indicates,3 one important step toward reducing the burden of disease for mental disorders and improving access to mental health services is to increase training for nurses and to increase the number of nurses specialising in this sector. At the same time, the survey results suggest that expansion of the scope of practice of nurses will encompass authority to assess, identify, and treat common mental health disorders.
*Tesfamicael Ghebrehiwet, Thomas Barrett
International Council of Nurses, 1201 Geneva, Switzerland (TG); and Department of Mental Health and Substance Abuse, WHO, Geneva, Switzerland (TB)
tesfa@icn.ch
TG was involved in the questionnaire for the survey on mental health nursing, sending it out, and providing feedback on responses. TB declares that he has no conflict of interest.
1 WHO. The world health report 2006—working together for health. 2006. http://www.who.int/whr/2006/en/index.html (accessed June 6, 2007).
2 Chang D, Xu Y, Kleinman A, Kleinman J. Rehabilitation of schizophrenia patients in China: the Shanghai model., In: Cohen A, Kleinman A, Saraceno B, eds. World mental health casebook: social and mental health programs in low-income countries. New York: Springer, 2002: 27–50.
3 WHO. Atlas: nurses in mental health 2007. Geneva: WHO, 2007.
Red Cross nurse counsels mother whose child was killed in Beslan school siege, North Ossetia
Users’ networks for Africans with mental disorders
Users’ networks for people with mental health disorders have emerged in Africa over the past 5 years, notably in Zambia, Uganda, Tanzania, Kenya, and South Africa.1 These organisations believe in users’ power to strengthen their sense of identity and improve the situation in their communities and countries. Users’ networks organise activities such as awareness campaigns and self-help projects, and they contribute to the development of mental health services, springing from the desire to attain human freedom that governments and communities continue to ignore.2
In Lusaka, Zambia, where there is a population of 2 million, the number of registered members is 220 of the estimated 30 000 people with mental health disorders. The remaining people with mental disorders are being reached through a track and trace project in conjunction with the government. The network in Zambia has a close working relationship with the government, which financially supports some programmes. However, funds to support the network’s activities are still scarce, making it difficult to operate effectively.
According to the 2004 World Mental Health Survey,3 200 000 people with mental health disorders (of an adult population of 5 million) in Zambia are not treated in an evidence-based manner. Most have been neglected, whereas others are hidden away by families that are ashamed of having a relative with such a disorder. A case study about stigma and discrimination against mentally ill people in the Lusaka community, which was done by the Zambian users’ network and sponsored by the World Psychiatric Association, showed that people with mental health disorders are not treated with respect, are neglected by families, and are denied opportunities for self-development.4
Zambia has an extended family system that harbours several cultural beliefs and practices—eg, bewitchment, sorcery, demonic possession, and ritual cleansing—which have implications for the mentally ill and for people’s perceptions of mental illness.5 The community perception is that people with such disorders are violent and dangerous, and hence should be locked in institutions or excluded from society because they are regarded as being unable to lead a normal life.6 Unfortunately, these practices delay people from seeking mental health services and interfere with the modern treatment of mental illness, which can contribute to some patients becoming chronically ill. Subsequently, families tend to suffer the burden of care with the search for treatment consuming meagre resources. This burden of care becomes frustrating, leading to hostility towards people with mental disorder and promoting admission to hospital or abandonment.7
As Gro Harlem Brundtland said in the 2001 WHO report,8 scientific knowledge about mental illness is available and there is no need for communities to still show ignorance, viewing mental illness from a cultural perspective that does not promote humane treatment.
Mental health care in Zambia does not have a well-coordinated system and is compounded by shortages of trained personnel, insufficient funds and facilities, and shortages of drugs, all of which have adversely affected quality of care.5 The archaic law also compounds the problem of stigma and discrimination by criminalising patients with mental health disorders, describing them as imbeciles or idiots and encouraging communities to characterise them in derogatory terms.6 This stigmatisation is seen in the violation of human rights that patients face in communities and by the promotion of admission to hospital.
To improve the situation in mental health care, governments should place mental heath on the national agenda by developing new legislation, policies, and programmes that are based on scientific knowledge and human rights for people with mental health disorders.9 To achieve this goal, there is a need for political will to promote mental health and to secure funding for the sector. Furthermore, the involvement of consumers and family members is crucial because they can assist in developing services that are tailored to people’s needs.8 Community mental health should also be promoted so that this sector can tap into community resources to tackle mental health disorders, because they originate from societies themselves.
Sylvester Katontoka
Mental Health Users Network of Zambia, Lusaka, Zambia
usersmentalhealth@yahoo.com
I declare that I have no conflict of interest.
1 Pan Africa network of users and survivors of psychiatry. First consumer conference report. General Inaugural Assembly, Kampala, Uganda, Nov 23–24, 2005.
2 WHO. Advocacy for mental health. Geneva: World Health Organization, 2003: 17.
3 The WHO World Mental Health Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291: 2581–90.
4 Mental Health Users Network of Zambia. Stigma and discrimination in Zambia. Lusaka: Mental Health Users of Zambia, 2005.
5 Zambian Ministry of Health. Mental healthy policy. Lusaka: Ministry of Health, 2005.
6 Zambian Ministry of Health. Mental Disorder Act. Lusaka: Ministry of Health, 1951.
7 WHO. Investment in mental health. Geneva: World Health Organization, 2003: 8.
8 WHO. World health report. Geneva: World Health Organization, 2001.
9 WHO. Mental health legislation and human rights. Geneva: World Health Organization, 2003: 2.
Mental health and the mass media: room for improvement
The mass media exerts a powerful influence on public attitudes about mental health. However, the message that often comes across reinforces negative stereotypes about people with mental illness: they are strange, unpredictable, and probably dangerous.1,2 Improvement of this situation will need effort on the part of both media and mental health professionals.
Earlier this year, an event in the small university town of Blacksburg, VA, USA, thrust mental health into the spotlight of the international media. On April 6, 2007, a student at Virginia Tech University opened fire in a dormitory and then a classroom, killing 33 people, including himself. A deluge of media coverage followed, much of it focused on issues related to the mental health of the shooter, Seung-Hui Cho. Several aspects of this coverage reflect broader themes common in media coverage of mental health.
“There’s no way you can plan for a psycho and that’s clearly what we’re dealing with here”, CNN commentator Jack Cafferty opined hours after the shootings,3 before the identity of the shooter (as well as information about his mental health) had been made public. The rush to link homicide with mental illness is not new4 and indicates the common misconception that mental illness goes hand in hand with violence. In fact, most people with psychiatric disorders are not violent,5 and although mental illness could have had a role in the Blacksburg rampage, this broader perspective was often lost in the ensuing coverage. Some reports gave the opposite impression. A week after the shootings, the Wall Street Journal reported that the shootings at Virginia Tech had prompted business managers to “rethink an array of security issues, particularly how to identify mentally ill people in their midst before they harm others or themselves”.6
In the days after the shootings, many media outlets ran stories on the reaction of the Korean-American community, members of whom were shocked and saddened that the killer was one of their own. Some feared that the shootings could lead to prejudice against them among the general public.7 However, few reporters sought the perspective of mental health consumers, many of whom presumably had similar fears of being judged guilty by association. As the discussion in the news media turned to issues about the rights of people with mental illness (eg, laws for involuntary psychiatric commitment, privacy of mental health records, and restrictions on purchasing firearms), the opinions of individuals with the most at stake were rarely heard.
Cafferty was hardly alone in using derogatory slang to refer to the killer. “Psycho penned poison plays” blared a headline in the New York Post8 days after the shooting. The Sun, a UK newspaper, variously referred to Cho as a crazed killer and a maniac.9 Criticism of such language in this case could be overzealous political correctness, yet it is worth asking why derogatory labels related to mental illness still appear in the media, whereas slurs based on race or physical disabilities are widely regarded as unacceptable, even in describing perpetrators of serious crimes.1 The likely answer is that members of the media are susceptible to the same prejudices and misunderstandings about mental illness that prevail in the general public.
Despite such shortcomings, the media also have the power to bring about positive change. Media coverage of the Asian tsunami in 2004 and Hurricane Katrina in 2005 brought attention to the psychological effect of disasters and the paucity of mental health services in some of the affected areas. Several news and editorial articles in the Oregonian newspaper in 2005 led to the closure of a decrepit and overcrowded state psychiatric hospital, and helped persuade lawmakers to pass bills funding more community-based mental health services and to induce insurers to provide equal coverage for mental and physical illness (and won the Oregonian a Pulitzer Prize for editorial writing in 2006).
Those of us in the news media have an obligation to be accurate and fair in all that we cover. For mental health coverage, accuracy and fairness mean avoiding stereotypical and stigmatising language, and seeking the opinions of mental health consumers in matters that concern them. Journalists seeking guidance on these points can consult resources compiled by several governmental, professional, and advocacy organ-isations, including: SHIFT, an antistigma campaign sponsored by the National Institute of Mental Health in England;10 the US National Institute of Mental Health;11 and the US Dart Center.12 Mental health professionals and consumers can help improve coverage of mental health issues by engaging and educating members of the media. Without open lines of communication, little will change.
Greg Miller
Science, San Francisco, CA 94110, USA
gmiller@aaas.org
I declare that I have no conflict of interest.
1 Wahl O. Media madness. Rugters University Press: New Brunswick, NJ, 1995.
2 Morris G. Mental health issues and the media. New York: Routledge Press, 2006.
3 CNN transcripts. Deadliest shooting rampage in U.S. history. April 16, 2007. http://transcripts.cnn.com/TRANSCRIPTS/0704/16/sitroom.02.html (accessed Aug 16, 2007).
4 Nairn R, Coverdale J. Imputations of madness in print media depiction of a mass killing. Aust J Commun 2006; 33: 143−61.
5 Friedman RA. Violence and mental health—how strong is the link? N Engl J Med 2006; 355: 2064−66.
6 Hymowitz C. Bosses have to learn how to confront troubled employees. Wall Street J April 23, 2007: B1.
7 Steinhauer J. Korean-Americans brace for problems in wake of killings. New York Times April 19, 2007.
8 de Kretser l, Sheehy K. Psycho penned poison plays: class horrified by psycho dad and chainsaw mother. New York Post April 18, 2007. http://www.nypost.com/seven/04182007/news/nationalnews/psycho_penned_poison_plays_nationalnews_leela_de_kretser_and_kate_sheehy.htm (accessed July 2, 2007).
9 Smith E, Clench J. Maniac put blame on classmates. Sun April 20, 2007. http://www.thesun.co.uk/article/0,,2-2007180398,00.html (accessed July 2, 2007).
10 SHIFT. Media. http://www.shift.org.uk/media.html (accessed Aug 20, 2007).
11 National Institute of Mental Health. Reporting on suicide: recommendations for the media. April 20, 2007. http://www.nimh.nih.gov/suicideresearch/mediasurvivors.cfm (accessed May 15, 2007).
12 Dart Center for Journalism & Trauma. Resources. http://www.dartcenter.org/resources/index.html (accessed May 15, 2007).