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Stop exclusionDare to care

W O R L D H E A L T H D A Y 2 0 0 1

World Health Organization

M E N T A L H E A L T H A R O U N D T H E W O R L D

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On 7 April 2001, all peo-ples and governmentsaround the world willobserve World HealthDay. This year is devotedto mental health. We

focus on mental health in recognitionof the burden that mental and braindisorders pose on people and familiesaffected by them, and with the aim tohighlight the important advancesmade by researchers and clinicians inreducing suffering and the accompa-nying disability. Our message is one ofconcern and hope.

The road ahead is long. It is litteredwith myths, secrecy and shame. Rareis the family that will be free from anencounter with mental disorders orwill not need assistance and care overa difficult period. Yet, we feign igno-rance or actively ignore this fact. Thismay be because we do not have suffi-cient data to begin addressing theproblem. In other words, we do notknow how many people are not get-ting the help they need – help that isavailable, help that can be obtained atno great cost. And, because we lackthis knowledge, we have not donewell to address mental and brain dis-orders. As we fail to acknowledge thisreality, we perpetuate a vicious cycleof ignorance, suffering, destitutionand even death. We have the capacity

– within us – to tackle the next fron-tier. Within people, within societies,within governments. Together wehave to work to make the change.

An estimated 400 million people alivetoday suffer from mental or neurologi-cal disorders or from psychosocialproblems such as those related toalcohol and drug abuse. Many ofthem suffer silently. Many of themsuffer alone. Beyond the suffering andbeyond the absence of care lie thefrontiers of stigma, shame, exclusionand, more often than we care toknow, death.

The simple truth is that we have themeans to treat many disorders. Wehave the means and the scientificknowledge to help people with theirsuffering. Governments have beenremiss in that they have not providedadequate means of treatment to theirpeople. And people have continued todiscriminate against those that sufferfrom these disorders. Human rightsviolations in mental hospitals, insuffi-cient provision of community mentalhealth services, unfair insuranceschemes and discriminatory hiringpractices are only some of the exam-ples. By accident or by design, we areall responsible for this situation today.

The time for reckoning is now. Let uslook at this day as an opportunity and

a challenge. A day to reflect uponwhat remains to be done and how wecan do it. Let us use this day and theweeks ahead to take stock and advo-cate for policy changes on the onehand and attitude changes on theother. Together with our MemberStates, let us pledge to work towardsa day when good health will alsomean good mental health.

This past century has seen spectacularchanges in the way we live and think.Human brilliance and technology havecome together to propose solutionswe dared not imagine fifty years ago.We have conquered diseases thatonce seemed insurmountable. Wehave saved millions of people frompremature death and disability. Andour search for better solutions tohealth is, as it should be, ceaseless.The solutions to mental health prob-lems are not difficult to find; many ofthem are already with us. What weneed is to focus on this as a basicnecessity. We must include solutionsand care for mental health in oursearch for a better life for all in a systematic way. Only then will oursuccesses be more meaningful. On this day, we must commit to “Stop exclusion – dare to care.”

Address by Dr Gro Harlem Brundtland

Director-General of the World Health Organization

F O R E W O R D

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I N T R O D U C T I O N

Mental health is an integral compo-nent of health through which a personrealizes his or her own cognitive,affective and relational abilities. Witha balanced mental disposition, one ismore effective in coping with thestresses of life, can work productivelyand fruitfully, and is better able tomake a positive contribution to his orher community. Mental and brain dis-orders, by affecting mental health,impede or diminish the possibility toreach all or part of the above. Pre-venting and treating them clears theroad to achieving one’s full potential.

As mental health is a fundamentalbuilding block for human develop-ment, we must face the facts thatmental health problems are a part oflife, that they can arise and that theycan be addressed.

Stop Exclusion

There is no justification in ethics, sci-ence or society to exclude personswith a mental illness or a brain disor-der from our communities. There isroom for everyone.

The health care system can lead theway. No rationale exists for excludingmental health services from the gen-eral health care system. Paritybetween physical and mental healthis vital.

Dare to Care

Don’t fear those experiencing a men-tal illness. It can happen to anyone.

Don’t ignore early warning signs.

Dare to challenge the myths and themisconceptions.

Provide better care; ensure access tocare, insist on equity in care. All thismust be done and all this is possible ifwe dare to believe that mental healthcare is a basic health concern for all.

Introduction

C O N T E N T S

Myths hurt – face them

Facts help – use them

Mental health today

A vision for the future

Where to learn more

M Y T H S H U R T – F A C E T H E M

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“Pull yourself up – it's all in yourimagination.” How often have weheard that? It’s not just friends andfamily that fail to grasp the existenceof a mental disorder. Even govern-ments choose ignorance, as seen bythe fact that mental health is oftenexcluded from their health prioritiesand plans.

Mental disorders are real

Mental illnesses and brain disordersprovoke suffering, cause disability andcan even shorten life as we see fromepisodes of depression after a heartattack, numbers of liver disease result-ing from alcohol dependence or casesof suicide. The existence of mentaland brain disorders often remains hid-den, voluntarily by the patient or sim-ply unrecognized as a real illness bythe person and their family. Yet theunderlying abnormal substructure ofmany disorders has been identified byimages of the brain. Thus to ignoretheir existence is akin to denying thatcancer exists because we are unableto see the abnormal cells without amicroscope. Mental illnesses can bediagnosed and treated before it is toolate.

The symptoms are a sign ofreal illness

There are people who suffer fromoverwhelming fears that are accompa-nied by a host of recognizable symp-toms. Others grapple with constantnegative or unpleasant thoughts andturn to alcohol to escape. In somecases, the patient’s pain can be soexcruciating that suicide is seen as arelief. In the year 2000, there willhave been an estimated one suicidedeath every 40 seconds.

It is easy to ignore or dismiss manysymptoms, yet the fact is that five outof the ten most disabling disorders arepsychiatric in nature. Unipolar depres-sion, alcohol use, bipolar affectivedisorder (manic-depression),schizophrenia and obsessive-compul-sive disorder are among the 10 lead-ing causes of disability world-wide in1990. The disability associated withmental or brain disorders stops peoplefrom working and engaging in othercreative activities, e.g., a mother maycease caring for a baby, an adolescentmay stop socializing with peers, andan elderly person may no longer takecare of himself or herself.

Are mental and brain disorders just a figment of one’s imagination ?

No. They are real illnesses that causesuffering and disability.

“If someone has a broken arm, you feel sorry for them. But when

(the problem is) psychiatric, people don’t know how to react because

they can’t see anything. But just because you can’t see someone’s pain,

it doesn’t mean they don’t need your care and support.”Samoan woman, manic depressive, 29 years old, Auckland, New Zealand

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Mental and brain disordersaffect adults, elderly,children and adolescents

Approximately one in five of theworld’s youth (15 years and younger)suffer from mild to severe disorders. Alarge number of these children remainuntreated as services simply do notexist. The majority of treatments havebeen traditionally geared to adultpatients, ignoring the need for earlyintervention in childhood.

■ Some 17 million young persons inthe 5-17 age group in Latin Ameri-ca and the Caribbean are affectedby mental or brain disorders severeenough to require treatment.

■ A study has shown that 10% ofschool children in Alexandria, Egyptsuffer from depression. Anxietyamong the secondary-level schoolchildren in their final year of schoolwas found to reach 17% in thisstudy.

Mental and brain disordersare a concern for bothdeveloped and developingcountries

No nations and no peoples are spared:

■ In a landmark WHO study in 27developing and developed coun-tries, no population has been foundto be free of schizophrenia.

■ Alcohol abuse is another commondisorder that knows no boundaries.For example, in Russia, 35,000 peo-ple die every year from fatal alcoholpoisoning.

■ Epilepsy is universal and more frequent in developing countries

■ A recent survey in a rural Pakistanivillage concluded that 44% of theadults were affected by depressivedisorders.

Do mental and brain disorders onlyaffect adults in rich countries?

No. All are affected – children and adults,rich and poor.

Number of persons world-wide withepilepsy (yellow) and schizophrenia (blue)(in millions) Source: The International League Against Epilepsy (ILAE) 1999

No one is immune.

Developed Countries Developing Countries

7

38

7.5

37.5


“You could get over it if you reallytried.” How often is this said? Yet, it isnot a question of willpower or effortalone. In some cultures, people mayalso consider that “immoral”behaviour or bad fate are responsiblefor mental health problems. Let us notsimply blame the person or poor luckbut try to understand the complexitiesof a mental or brain disorder.

Are mental or brain disorders broughton by a weakness in character?

No. They are caused by biological,psychological and social factors.

“Mental illness is one of the major afflictions of mankind that has

had little support in the past. During the last half century there has been

quite a revolution in the understanding and treatment of major mental

illness such as depression, schizophrenia, manic depression and anxiety.

Rather than a flaw in character or a consequence of a dysfunctional fam-

ily, recent research has shown that mental illness has biological

roots.” Julius Axelrod, 1970 Nobel Prize for Medicine in a letter to WHO Director-General on 30 June 2000

Research is beingconducted to determine thegenetic origins orbiological factors ofvarious disorders

Genes have been shown to be associ-ated with the origin of schizophreniaand Alzheimer’s Disease. Depression isknown to be associated with changes

in brain chemicals. Alcohol depen-dence, often branded as a vice result-ing from poor moral character, is nowlinked to both the social environmentand to genes. Mental retardation pro-vides another example. One biologicalcause of this disorder is the lack ofiodine, vital for brain development, inthe diet of a growing child.

Social influences cansignificantly contribute tothe development of variousdisorders

For example, individuals react differ-ently to stressful situations. Loss of aloved one can potentially lead to adepression. Loss of work is associatedwith heavy alcohol use, suicide anddepression. Poor nurturing environ-ments, whether they are the result ofbroken families or violence in thehome or community, can result in anincreased risk of mental illness.

In some places of the world, mentalillnesses are thought to be caused byevil spirits. This is a difficult issue. Itpits faith against fact, faith healersagainst doctors, cultural beliefs againstscientific knowledge. Perhaps to pre-vent a situation from taking a turn forthe worse, mental health professionalscan work with healers so that thosewho cannot be helped by traditionalmedicine can receive conventionaltreatments. Mental health profession-als serve the community better byunderstanding the cultural and socialcontext within which their work is tobe carried out.

Extreme poverty,war and

displacement caninfluence the

onset, severityand duration of

mental disorders.

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Something can be done for all mental andneurological disorders

Some people recover completely. Oth-ers have a more difficult time. But inall cases, there can be an alleviation ofsuffering through different methods.For example,

■ Schizophrenia, a severe disorder, istreatable. People suffering fromschizophrenia can be helped withmedication to reduce the symp-toms. A relapse can be preventedwith psychosocial interventionsaimed at the family, for the benefitof all.

■ Most recently diagnosed childrenand adults with epilepsy could havea complete control of seizures formany years, provided they receiveappropriate medicines.

■ Rehabilitation measures, aimed atenhancing social and personal skills,assist persons with depression toregain a normal life. Anti-depres-sant medication can also help inmany cases.

Help can be found from the medicalprofession on two levels.

The general health workers, such asphysicians and nurses, are the firstprofessionals whom one could con-sult. Most communities have access tothem but in some parts of the world,they are not prepared to address theemotional needs of their patients.With proper training and supervisionthese professionals could be betterequipped to identify and provideeffective treatment for mental andbrain disorders. A major stumblingblock is to lift the shame so that peo-ple will talk freely of their emotionalproblems with their family doctor.

The specialized health workers,including psychologists, psychiatrists(for mental disorders) and neurologists(for brain disorders), psychiatric andneurological nurses, social workersand occupational therapists provideexpert care where available.

It is not enough to assistonly the suffering person

The family, which constitutes the mainsupport system, needs support as wellto preserve its functioning and well-being. Such help is seldom received;more services for families need to bedeveloped in all countries.

Is it impossible to help someone with a mental or brain disorder?

No. Treatments exist and caregivers can be assisted.

Counselor meets with a mother and hermentally impaired child during a

counseling session in a community healthcenter

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The treatment of mental illness is mostoften associated with mental hospi-tals. Institutions that violate basichuman rights, stripping one's dignitythrough inhumane care still existtoday. Too often abandonment, con-finement, or isolation can be seen asthe only solution when confrontedwith an ill person. Yet, the facts showus that persons suffering from a men-tal illness or a brain disorder canimprove and contribute to society.

We have seen there are many possibletreatments available; there are alsobetter and more appropriate condi-tions in which we can provide thesetreatments.

Today, the picture in the world is farfrom perfect, but care is now avail-able in a variety of environments.People’s own homes, clinics, emergen-cy rooms, psychiatric wards in generalhospitals and day care centers are allviable options. Rehabilitation is carriedout in hostels, cooperatives, shelteredworkshops and through social supportgroups.

Like physical disorders, mental andbrain disorders vary in severity. Thereare those that are:

■ transient (like an acute stress disor-der);

■ periodic (like bipolar disorder, char-acterized by periods of exaggerat-ed elation followed by periods ofdepression);

■ long lasting and progressive (likeAlzheimer’s Disease).

Treatment must be appropriate to thedisorder, and take into account theindividual’s situation: is the personalone at home? Does he/she havefamily who could provide care togeth-er with the doctor or a nurse? Thebest alternative will depend on eachindividual, and in any situation, thehuman rights of people must be pre-served.

Should we just lock up persons withmental illness ?

NO. People with mental illness canfunction and should not be isolated or restricted.

Is this what we want ?


There are many other misconceptionsabout mental illness and brain disor-ders. To address them all here wouldbe well beyond the scope of thisbrochure. Take the time to exploreyour own personal prejudices andunfounded beliefs.

We should all recognize that personswith mental illness suffer not only onaccount of their illness. They are oftensocially stigmatised, if not con-demned. In everyday life, this impedesthat people:

■ reintegrate fully into society, obtaindecent housing, a paying job or areasonable social life. For a personwho has been discharged from apsychiatric hospital, such exclusionmay lead him back to the hospital;

■ go for treatment when necessary,for fear that the search for help beknown to others causing a loss ofsocial status to both the person orthe family. This is a serious problemsince suffering is not relieved andfunctioning or quality of life may beaffected as the disorder continues.

The myths surrounding mental healthproblems are responsible for terribleshame and contribute to the low lev-els of treatment.

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“ I experienced homelessness at one stage coming out of the hospi-

tal. I had nowhere to go. I had no other choice. My family at that point was

struggling with their own view of my condition and there was no place in

the family for me. If my family had been educated, taught how to help me,

supported and helped, then my story would be very different. Families need

to be involved – they are after all the ones we rely on the most.”Woman with a schizophrenic disorder, 43 years old, New Zealand

“ I am the main care-giver for my husband’s brother, who is

schizophrenic. The families of the mentally ill … need to know that they are

not to blame for the illness that has torn their family apart. Shame and fear

build walls of silence. Now is the time to speak out so that families can

know that they are not alone, that they have nothing to be ashamed of. The

public must be educated to recognize symptoms, to know that mental illness

can strike anywhere and to understand that help is available.”Mrs. Kathy Esquivel, wife of former Prime Minister of Belize, Central America

F A C T S H E L P – U S E T H E M

What is it?

Schizophrenia is characterized by pro-found disruption in thinking and feel-ings, affecting language, thought,perception, and sense of self. It oftenincludes psychotic experiences such ashearing voices or holding fixed abnor-mal beliefs, known as delusions.

How many suffer?

Around 45 million persons world-wideabove the age of 18 suffer fromschizophrenia at some point in theirlives. The disorder has been found inall nations where studies have beenconducted. It begins at a young ageand can impair functioning causingthe loss of an acquired ability (i.e., notbeing able to gain one's own liveli-hood or disruption of studies).

What can be done?

Research has advanced the under-standing of the disorder and mademajor contributions to the treatment.Treatments are both of a biologicalnature (e.g. medication) as well aspsychosocial (e.g. psycho education ofthe family and rehabilitation). Thehelplessness of the past has beenreplaced by considerable hope sinceconditions that once were treated in

closed institutions have been givingroom to interventions at home, incommunity services, general hospitalsand hostels. Psychosocial rehabilita-tion has made considerable strides andhas enabled patients to find a place inthe workforce, in their families andcommunities. Early treatment is essen-tial for better recovery.

Schizophrenia

“My first-born son, today aged 39, was first hospitalized at age

17 for about four months, some four years after his mother died of can-

cer. The official diagnosis of schizophrenia was disclosed to me only five

years after its onset.

“For about ten years while at home, my son refused to take medication

due to adverse side effects, refused to see doctors leading to extreme

confrontations. For the last five years he is being treated with medica-

tion and his condition has stabilized. He now lives in a very decent hos-

tel [half way home] and works in supervised employment for few hours

every working day. His social life and personal relations are much

improved.

“Beyond the personal saga, I gained extensive experience in the last

years. I am involved as member – and recently as chairman – of a family

organization. I strongly believe that today most schizophrenia patients

and their families can avoid the via dolorosa we went through, if using

adequate combinations of medication and psycho-social rehabilitation –

with strong emphasis on the latter. This, however, requires drastic reform

– beyond lip service – by the medical establishment and the public

authorities – in the allocation and proper use of the public health funds

and manpower. Our families’ organization is committed to struggle to

achieve this reform, but it is still a steep uphill struggle.”Father of a person with schizophrenia from Israel

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Africa

Americas

Eastern Mediterranean

Europe

South East Asia

Western Pacific

Number of people with schizophrenia world-wide (in millions)


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What are they?

Depressed mood and loss of interestand pleasure characterize these disor-ders. If they alternate with exaggerat-ed elation or irritability they areknown as bipolar disorders (one pole,depressed; another pole, elation ormania). Their severity, the symptomsthat often accompany the depressedmood and the duration of the disorderdifferentiate them from normal moodchanges that are part of life.

The causes of these disorders vary,there are psychosocial risk factors thatinfluence the onset and persistence ofthe depressive episodes as well as bio-logical factors of different kinds.

How many suffer?

Studies demonstrate that one out ofseven adult persons in the USA have amood disorder during a single year,7% in Brazil, almost 10% in Germanyand 4.2% in Turkey. In the USA, 5%of children aged 9-17 were found tohave depression, a disorder thought tospare youth and adolescents. Ignoringthis reality can result in suicide.Depressive disorders and schizophreniaare responsible for 60% of all suicides.

What can be done?

Despite the existence of solutions, themajority of people with depression donot receive adequate treatment. Thisimplies that there are millions of peo-ple in the world currently affected bythe disorder whose suffering and dis-ability is prolonged because their con-dition goes undetected or, often, isnot well treated. A reluctance to speak

about ones feelings or poorly trainedmedical personnel can be at the rootof this. Fortunately, there are nowclear guidelines for the treatment ofmood disorders which include bothantidepressant medications and psy-chological interventions, such as cog-nitive psychotherapy and socialsupport.

“I am about fifty-seven years of age. I had never experienced any

odd or abnormal state of mind. Neither had I ever known any such thing

about any of my family members. By nature I am a very contented per-

son, generally very helpful and cooperative, even to my casual acquain-

tances. Holding a very senior position in a leading educational

institution, I have no problem with my job, status and family.

“In the month of April 2000 all of a sudden I observed certain changes

in my mental make-up. Though there was no personal provocation I

developed a kind of phobic anxiety, started attaching motives to hap-

penings and persons around. There was a feeling of undue sadness, lack

of vigour and inability to concentrate on work and personal matters. I

started losing interest in all normal activities; loss in weight, appetite

and sleep was also experienced, thus causing so many simultaneously

occurring complications, both physical and mental.

“I was diagnosed with depression and assured that it was curable. I reli-

giously followed my doctor’s instructions. I have visited him four times

and have the satisfaction that with the grace of the Almighty and with

the able handling by the esteemed Doctor, I have regained my confi-

dence and have restarted taking interest in all normal activities

around.” Male patient from India

Depressivedisorders


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What is it?

Epilepsy is a brain disease character-ized by repeated seizures (“fits”)which may take many forms, rangingfrom the shortest lapse of attention tosevere and frequent convulsions. Thecauses are multiple, e.g., trauma tothe brain, infections such asencephalitis, parasites, alcohol orother toxic substances. However, inhalf of the cases, the causes remainunknown. Epilepsy is treated by neu-rologists when available or by psychia-trists in many other places.

How many suffer?

It is estimated that about 45 millionpeople of all ages around the worldare affected by epilepsy, while 1% ofthe total burden of disease in theworld results from it. This calculationof the burden of disease takes intoaccount premature deaths resultingfrom the disease as well as the loss ofhealthy life years due to disability. Thenumber of people with epilepsy isover five times higher in developingcountries than in developed countries.

A vast majority of those sufferingremain untreated. Take the case inAfrica, for example, where up to 80%of people suffering from epilepsy donot receive any treatment at all.

What can be done?

The solutions exist so that up to 70%of newly diagnosed cases can be suc-cessfully treated with anti-epilepticmedication that is taken without inter-ruption. After 2-5 seizure free years,the anti-epileptic medication may begradually withdrawn in 60-70% ofthe cases, provided the physician indi-cates such a course of action. Yet thehealth care system in many places has

failed to recognize or find those withepilepsy and in some cases, has failedto provide the right treatment tothose it has recognized. The importantthing to note for a disorder so fre-quent is that there are medicationswhich are both effective and cost effi-cient. Given their low price, they arean affordable remedy in all countries.

Epilepsy


Bet-El School for children with epilepsy run by the NGSK Church in Cape Town, South Africa

Treatment gap in developing countries 1988-1996

% of ill persons not receiving treatment in yellow.

Source: The International League against Epilepsy 1999.

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What is it?

Alzheimer’s Disease is a form ofdementia which destroys brain cells,disrupting the transmitters which carrymessages in the brain, particularlythose responsible for storing memo-ries. It is one of the most commontypes of dementia world-wide andaccounts for 50% to 60% of all cases.Dementia is a progressive degenera-tive brain syndrome which affectsmemory, thinking, behaviour andemotion. Symptoms may include aloss of memory, difficulty in findingthe right words or understandingwhat people are saying, difficulty inperforming previously routine tasks,personality and mood changes.

How many suffer?

There are currently estimated to beabout 11 million people world-widewith Alzheimer’s Disease. This figure isprojected to nearly double by the year2025.

The late stage of Alzheimer’s Diseaseis one of total dependence and inac-tivity. At this stage individuals are nolonger able to care for themselves anddo not recognize relatives, friends andfamiliar objects. This represents anenormous burden on families and thehealth care system.

A study by the American Alzheimer'sAssociation in 1998 has shown thatthis disease costs US businesses US$33billion a year; US$26 billion related to

the absenteeism of caregivers –employees who take care of peoplewith the disease, with businesses con-tributing another US$7 billion towardthe total cost of care. There are noglobal figures as yet for the financialimpact of Alzheimer’s Disease.

What can be done?

There is currently no cure forAlzheimer’s Disease. Over the last fiveyears there has been a growth in thenumber of drugs being developed orconsidered for use in people withdementia, particularly Alzheimer's Dis-ease, which seem to provide symp-tomatic relief for some patients.Interventions given by family care-givers can reduce the family’s distressand that of the person withAlzheimer’s Disease, as well as delayingnursing home placement where this isavailable. Support for persons withAlzheimer’s Disease and their familycan come from different sources but isoften of limited availability. Voluntaryorganizations such as Alzheimer’s Dis-ease associations give practical andemotional help as well as training forcaregivers and professionals.

“ I now deeply regret that I was irritated by my husband’s

behaviour instead of being considerate of him in such a situation, as I

did not understand what was wrong. Eventually at the age of 55, (my

husband was) diagnosed (with) Alzheimer’s Disease. I attended the care-

giving study class at the public health centre with my husband. On a

public health nurse’s recommendation, my neighbours kindly attended

the centre to increase their knowledge of the disease. I was helped by

them enormously after his wandering started. Although I feel I will never

be able to accept my husband’s disease, I would like to thank him for

giving me the opportunity for mental development.”A woman’s story from Japan

Alzheimer’sDisease

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Ecuador

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What is it?

The World Health Organizationdefines mental retardation as a condi-tion of incomplete or halted develop-ment of the mind, which ischaracterized by the impairment ofskills as manifested during the devel-opmental period that contributes tothe overall level of intelligence, e.g.,cognitive, language, motor and socialabilities.

How many suffer?

It is estimated that the number ofindividuals with mental retardationdiffers in relation to the level of coun-try development. The percentage ofyoung persons, aged 18 and below,suffering from severe mental retarda-tion reaches 4.6% in the developingnations and are estimated to bebetween 0.5%-2.5% for the estab-lished economies. The differencebetween both figures indicates that,potentially, preventative efforts madeto reduce mental retardation, such asbetter maternal and child health careas well as specific social interventions,could result in an overall decrease ofmental retardation worldwide.

What can be done?

The mental potential of all persons,including of those who are limited byretardation, can either be developedor wasted. A positive attitude coupledby appropriate educational and voca-tional programs can help those withmental retardation to adjust and suc-ceed by performing at their highestlevel. To achieve such goals, servicesneed to be provided and self helpgroups, of both families and individu-als, need to be fostered. The empow-erment of parents could accelerate theformulation of healthy policies, pro-grams and services.

Mentalretardation

“The Lonely Flower” painting by a severely mentally retarded adult.


What is it?

Alcohol dependence is a mental disor-der recognizable by symptoms whichcan include a strong and persistentdesire to drink despite harmful conse-quences, inability to control drinking,a higher priority given to alcohol con-sumption than to other activities andobligations, tolerance to alcohol, anda physical withdrawal reaction whenalcohol use is abruptly discontinued.

Alcohol can trigger health problems ina large number of problem drinkers(alcohol dependent or not), includingaccidents and injuries, heart disease,cancer, liver disease and alcohol psy-chosis. Alcohol is also related to socialproblems including crime, violence,marital breakdown, poor school per-formance, high rates of work absen-teeism, suicide and financial debt.

How many suffer?

While there are an estimated 140 mil-lion alcohol dependents in the world,there are over 400 million people whodrink excessively and can cause acci-dents, injuries, suffering and death.There is no reason to blame only“alcoholics”. Excessive alcohol use is aleading cause of PREVENTABLE death,illness and injury. In 1992 the eco-nomic cost to society from alcohol inthe United States was an estimatedUS$148 billion, while studies in othercountries have estimated that the costof alcohol related problems rangebetween 0.5% and 2.7% of the grossdomestic product.

■ 140 million alcohol dependents

■ 78% are not treated

■ Alcohol is responsible for 1.5% ofall deaths in the world

What can be done?

It is very hard to determine exactlywhen a person has become depen-dent on alcohol and by that time arange of problems may have alreadyoccurred to the individual and others.As a result, assessing levels of alcoholconsumption is the most effective wayto identify problem drinkers early. Forthose at risk, brief interventions ofonly five minutes can lead to a 25%reduction in alcohol consumption,preventing progress to more severeproblems, including alcohol depen-dence.

Treatment of alcohol dependence andwithdrawl can be effectively carried outin community settings for most cases.Voluntary mutual help organizationscan also play a large role in supportingrecovery from alcohol dependence.However, measures aimed only attreating those who are dependent arenot enough. Effective alcohol controlpolicies are also needed.

Alcoholdependence “I went to a party, Mom.

I went to a party,

and remembered what you said.

You told me not to drink, Mom

so I had a Sprite instead.

I felt proud of myself,

the way you said I would,

that I didn't drink and drive,

though some friends said I should.

I made a healthy choice,

and your advice to me was right

as the party finally ended,

and the kids drove out of sight.

I got into my car,

sure to get home in one piece,

I never knew what was coming, Mom

something I expected least.

Now I'm lying on the pavement,

And I hear the policeman say,

“The kid that caused this wreck was drunk,”

Mom, His voice seems far away.

My own blood's all around me,

as I try hard not to cry.

I can hear the paramedic say,

“This girl is going to die.”

I'm sure the guy had no idea,

while he was flying high,

because he chose to drink and drive,

now I would have to die.

So why do people do it, Mom

Knowing that it ruins lives?

And now the pain is cutting me,

like a hundred stabbing knives.

Tell sister not to be afraid, Mom

tell daddy to be brave,

and when I go to heaven,

put “Daddy's Girl” on my grave.

Someone should have taught him,

that it's wrong to drink and drive.

Maybe if his parents had,

I'd still be alive.

My breath is getting shorter, Mom

I'm getting really scared.

These are my final moments,

and I'm so unprepared.

I wish that you could hold me Mom,

as I lie here and die.

I wish that I could say I love you, Mom

So I love you and good-bye.”Author unknown, circulating on Internet

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M E N T A L H E A L T H T O D A Y

“Great numbers of mentally ill stilllive, shut away behind hopeless wallsby the prejudices and incomprehen-sion of society. The efforts of the mostadvanced psychiatrists to have thementally ill treated as other sick peo-ple, who can be cured, are likely toremain fruitless as long as irrationalfear of ‘madness’ is not conquered, aslong as all the influential members ofthe social hierarchy do not understandthat mental health is not only thebusiness of specialists but must con-cern the whole community.”

This statement was written forty yearsago, in a special issue of World Healthcommemorating World Health Day in1959. What is remarkable is that thisstatement is still reflected in the publicimage of mental health today. As werealize that the global perception andpractice in mental health remainsmuch as before, we can bring to lightthe incredible accomplishments inmany corners of the world. Today wehave the opportunity to take onegiant step forward collectively– out ofthe darkness – into the glimmeringrays of knowledge that many haveendeavored to bring forth. We knowmany things: mental and brain disor-ders are real illnesses, they are diag-nosable, treatable and in some caseswe know how they occur and how toprevent them. Anyone can be afflictedbut we pretend not to be concerned.

A change now needs to happen in ourhearts to accept the knowledge whichhas been gained and to adopt a newattitude about mental health. We arethe missing link – the minds of somebillion souls – that should come torealize that one’s mind and brain canbecome sick but can also be healed,just as the body.

We are on the path around the worldto improve the care of persons withmental or brain disorders.

The United Nations Commission ofHuman Rights stated not only thatmedical treatment should be consid-ered as a basic right for people suffer-ing from mental illness, but also thatthose people have to be protectedfrom potential dangers. This was farfrom the case for centuries of mentallyill patients. While some countries havebeen moved to change this situation,still others have not. Violations ofhuman rights can be perpetrated bothby neglecting the patient throughcarelessness and by forcing him/herinto restraining or even violent caresystems. Even under optimum circum-stances, persons with mental illness inmost countries are often powerless.Yet, family members and patientsthemselves can try to influence mentalhealth policy and service organiza-tions.

Taking stock

Reorienting Mental Health services

Group health session in Venezuela

Latin America – an exampleof the “consumer”movement

In the early 1990’s, throughout LatinAmerica care for persons with severemental disorders was mostly providedin outmoded mental institutions thatoften violated human rights. Out-raged by this situation, a group ofparliamentarians, mental health work-ers, media, consumers and advocates,representing eleven countries gath-ered in Venezuela to analyse mentalhealth care and suggest ways toupgrade it. The Caracas Declarationwhich resulted from this historicalmeeting has given further impetus toa movement of reform in mentalhealth care that was on the making inseveral countries of Latin America.


Brazil is one example where consider-able strides have been made. Activeparticipation of patients themselvesin the formulation of policies to over-come past inequities provides astrong voice and vitality to a processof change that is moving the carefrom closed institutions into the com-munity. Change is resisted by somequarters, often as a result of ill-con-ceived notions and traditions, yetobservers of the Brazil case note thatthe patients keep the agenda movingforward and force the pace of thisreform among both professionals andsociety at large. The struggle has beentaken to the streets and into thechambers of the parliaments. Brazilhas developed innovative pro-grammes, such as the one in the cityof Santos, State of Saõ Paulo, wheremental hospitals of yesteryear havegiven room to alternative settings ofcare and where consumers are gain-fully employed by co-operatives.

Chile is another example of a countryresolutely moving forward to trans-form its services. Today, communityclinics are mushrooming all over itsterritory although, admittedly, someareas are yet to be covered. Movingnorth, in Central America, Panamaand Belize, among other countries, areinnovating the type of servicesoffered. Belize, for instance, with justa single psychiatrist working in thecountry, has multiplied its resources bytraining family nurses known as psy-chiatric nurse practitioners, entrustedwith the provision of mental healthcare. A recently conducted evaluationhas shown that the public is satisfiedwith their services, now offered allover the country. Despite theseimprovements, there is still a long wayto go to reach the aims that theauthors of the Caracas Declarationhad in mind. In Latin America, somepopulations do not have mentalhealth coverage, many services remainsubstandard and human rights viola-tions have not been banished.

De-institutionalization and human rights – the case in Europe

De-institutionalization (providing careto the mentally ill in community set-tings and not in harmful institutions) isvery closely related to human rightsconcerns and represents a basic precon-dition of any serious mental health carereform. De-institutionalization is not themere administrative discharge ofinmates’ populations leading to dra-matic patient neglect. On the contrary, de-institutionalization is a complex pro-cess, where de-hospitalization mustlead to the implementation of a net-work of alternatives, outside of thewalls of the mental hospital. A morepositive notion of “non-institutionaliza-tion”, with emphasis on communityalternatives should be the norm in allcountries.

In Italy, the 1978 Mental HealthReform began a process of “human-ization” of the psychiatric hospitalsand led to the creation of communitybased services capable of enablingpatients to live in normal environ-ments. The Italian city of Trieste hascreated an impressive network ofcommunity based services, protectedapartments and co-operativesemploying mentally ill persons. Thepsychiatric hospital in Trieste wasclosed down and replaced by commu-nity mental health services operating24 hours a day. These centres providemedical care, pyschosocial rehabilita-tion, social assistance and when nec-

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The Siauliai mental hospital in 2000

The Siauliai mental hospital in 1980

essary treatment of acute episodes. Anumber of protected apartments pro-viding a “non-medical” and friendlyenvironment for the most severelyand chronically ill were created. Final-ly, work opportunities have allowedmany patients to secure a substantialintegration into the community life.Many other European cities have wit-nessed a marked shift from hospital-based to community-based systemsleading to an important decrease ofmental hospital beds and, in somecases, the closing of the whole institu-tion. The Siauliai mental hospital inLithuania, for example, is on the roadto providing rehabilitation services andreintegration of psychiatric patientsinto the society. With the purchase ofa residential building this year,increased attention is given to psy-chosocial interventions aiming toensure that after treatment thepatients can independently function athome and in society. Similar scenariosof community mental health care arebeing built in other regions of theworld, yet still not in the generalizedfashion that we hope for.

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Mental health care is a basic andessential building block for ensuringlife-long good health. The family doc-tor and general practitioner need tobecome increasingly better able torecognize any potential mentalimpairment or brain disorder in orderto provide quality care. In many partsof the world, different methods arebeing utilized to address this concern.

One example from theMiddle East

An innovative approach for ensuringthat basic mental health services areavailable to all people, even the mostvulnerable and deprived groups, wasconceived in Iran in 1985 as the“National Mental Health Pro-gramme”.

A unique feature of the Iranian healthsystem is the integration of healthdelivery and medical education in oneministry. At the base of a pyramid

approach are the Health Houses inrural areas (and more recently HealthUnits in urban areas); each one isresponsible for the basic health needsof around 2000 people. These smallunits rely on human resources that arerecruited from the community andtrained. There is one community vol-unteer for every fifty families to assistthem in getting any necessary medicalattention. Health Centers grouptogether four or five health houses orunits and provide the services of aGeneral Practitioner. Such a center isin turn supervised by the DistrictHealth Center and has access to spe-cialist centers that are usually part of aUniversity of Medical Sciences andHealth Services. In each province ofthe country (population of sixty mil-lion), there is at least one such univer-sity which is in charge of health affairsof the province as well.

The integration of mental health carewithin this existing nationwide struc-

ture started as a test case in centralIran in 1987. Mental health responsi-bilities of each level were clearlydefined and appropriate training, fol-low-up and supervision provided. Themental health system is supported bya third specialized level composed of650 psychiatrists and about 10,000psychiatric beds, although most ofthem are still in large psychiatric hos-pitals. To gradually decrease thereliance on mental institutions, there isa standing decree from the Minister ofHealth and Medical Education that10% of the beds in all new generalhospitals should be used for psychi-atric care.

At present, the programme is activethroughout the country: almost 60%of the rural Health Houses and 25%of the Urban or Mixed Health Centerscomprising 5,500 general practitionersare active in providing mental healthservices.

This approach has been adapted byother countries in the region, such asBahrain, Cyprus, Egypt, Jordan,Tunisia, Saudi Arabia and Yemen.There is more than one recipe for suc-cess but this approach to integratingmental health care within a primaryhealth care system is a good testimo-ny to what may be accomplished inother parts of the world.

Mental health as part of generalhealth care services

Training of mental health professionals in Iran.


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Family involvement in the care andrehabilitation of persons with mentalor brain illness is being recognizedworld-wide as a key factor in success-ful treatment.

The case in South Asia

The family has been an essential partof mental health care programmes inSouth Asia for fifty years.

The first formal recognition of theimportance of the family as part oforganised mental health care can betraced to the mid 1950's in AmritsarMental Hospital, India. Patients werebrought for hospital admission as aform of abandonment once their men-tal illness was long-standing and theirrelatives had no more hope. As anexperiment, the relatives were encour-aged to stay with the patient duringthe treatment period by pitching tentson the hospital grounds. The successof this involvement led to other similarexperiments and the system of includ-ing a family member has become anessential part of psychiatric in-patientcare in all countries of the Region.

The focus of family interventions, todate, has been to build a relationshipwith caregivers based on understand-ing and empathy, and helping themto:

■ identify ways to promote medica-tion compliance;

■ recognize early signs of relapse;

■ ensure swift resolution of crisis;

■ reduce social and personal disabili-ty;

■ moderate the effect in the homeenvironment;

■ improve vocational functioning ofthe patient;

■ develop self-help groups for mutualsupport and networking amongfamilies.

More than 500 persons who werelong-stay patients in the mental hospi-tal have been rehabilitated in SriLanka, by community education andfamily involvement. In a number ofcities such as Jodhpur and Chennai inIndia, a camp approach to drugdetoxification has included the fami-lies as “partners in care”. The home

The empowerment of families

Woman with schizophrenia (holding child) in care at home with her family in India.

care programmes for elderly personswith dementia initiated in Kerala,India, is now spreading to other partsof the country. Another initiative istraining for home care and support tofamily members of mentally retardedindividuals. This has resulted in amovement that has generated voca-tional rehabilitation for the adult men-tally retarded individuals. Families of aperson with schizophrenic illness inmany cities (such as Bangalore, Chen-nai, and Gauhati in India, Katmanduin Nepal and Colombo in Sri Lanka)have come together to form self-helpgroups and start day care centres,half-way homes, hostels and to putpressure on the policy makers toimprove services for the mentally illpersons.

The successes of family care pro-grammes have still not received thefull support of professionals and plan-ners to the extent that it becomes aroutine part of psychiatric care. As weenter the 21st century, this mustbecome commonplace for everyonearound the world.

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Many countries in Africa are engulfedin conflict and civil strife resulting inan adverse impact on the mentalhealth and well-being of the affectedpopulations. It is estimated that thereare between 40 to 50 million refugeesand displaced persons worldwide. Ofthese, only 22.4 million receivehumanitarian protection and assis-tance and around 30% of these dis-placed persons are in Africa.Increasing poverty and lack of interna-tional legal consensus are some of themajor factors preventing most of therefugees from receiving support.

Wars, other forms of violence and dis-asters contribute to the growth ofpsychological and socio-economicburden. Family disruption with anincrease of abandoned children andwomen headed families; increase ofstreet children; juvenile delinquency;prostitution; and alcohol and drugrelated problems are a common sce-nario in a number of countries ofAfrica. All these stressful events con-tribute to anxiety, depression, differ-ent psychosomatic disorders, phobiasand post traumatic stress disorders.

Community BasedPsychosocial Interventions– the story in Africa

Community based approaches totackle mental health problems andother consequences of war and socialdisruption were recently the subject oftwo important inter-country meetingsinvolving Angola, Burundi, Chad,Congo, Democratic Republic ofCongo, Eritrea, Ethiopia, Lesotho,Liberia, Mozambique, Namibia, Rwan-da, Sierra Leone, South Africa, Ugan-da and Zimbabwe. These countrieshave embarked on different types ofcommunity based interventionsdespite the difficult conditions whichinclude:

■ prevention and promotion activi-ties such as peace education, con-flict resolution skills, prevention ofalcohol and drug abuse;

■ early detection and treatment ofphysical, psychological and socialproblems involving nutritionalrehabilitation, first aid for victims ofland mines and other forms ofinjuries, psychological supportusing school teachers and self-helpgroups;

■ rehabilitation through social reinte-gration, family reunification andthe promotion of human rights.

The involvement of community andreligious leaders, traditional medicinepractitioners, women and youth orga-nizations and self-help groups is veryeffective to ensure culturally sensitiveinitiatives.


Mental health counselling after floods in Mozambique.

Mental health care in countries in conflict


Recent changes in the socio-politicaldevelopment of many countries in theWestern Pacific Region have generat-ed considerable challenges which per-meate the lives of the people in thesecommunities. These changes affectthe structure of society, and are feltespecially in the mental health situa-tion of the population. Clearly, in situ-ations of transition economies,concerns for job security and the eco-nomic survival of the household canloosen social bonds and create enor-mous pressure on one’s mental healthstability. The resulting need for mentalhealth programs at all levels, forstrengthening promotion, preventionand care and for reorienting servicesto address the psychosocial issues of achanging society was addressed inMongolia.

Innovating mental health –one example from Central Asia

Mongolia is a country which is chang-ing from socialism to one with a mar-ket economy following a democraticpolitical reform in 1990. This changehas been affecting all aspects of Mon-golian life: political, economic andsocial life, especially impacting on thefamily. In 1997, the National HealthPolicy has articulated the shift from aspecialist to a generalist health caredelivery system. As a consequence,general health services are beingstrengthened, and hospital based carehas shifted to bring a greater empha-sis on community based health care.

Policy makers and governmentauthorities have recognized theimportance of mental health byspecifically including mental healthservices in the new national healthpolicy. As a consequence, appropriatetraining in mental health and psy-chosocial skills is provided to all gener-al health personnel. In addition, healthpromotion among youth to preventthe adverse effects of social changes(such as increased alcoholism, suicide,violence and criminality) has beenundertaken. In the last two years atleast 50% of general physicians inUlaanbaatar City as well as theprovinces in the eastern, western andcentral parts of the country have notonly undergone mental health train-ing, but have started to managepatients with mental health problemsin their clinics. These general physi-cians have also included mental healthtopics in their health education activi-ties in the schools and during their

home visits. Since 1999, the mentalhealth training has been expanded toinclude the community health work-ers; many of whom attend to thenomadic groups representing 40% ofthe Mongolian population.

Since 1998, a decrease in admissionand in the length of hospital stay atthe State Mental Hospital has beennoted. An increase in the number ofpatients treated in the general healthclinics as well as those referred to theoutpatient clinic and the Center forMental Health are also recorded. AMental Health Law, passed in 1999,provides for the continuation of thesereoriented programs in the country.

Mental health care in transition economies

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A V I S I O N F O R T H E F U T U R E

Mental health care is a collective andcontinuous undertaking. It implies act-ing to preserve and recover that whichmakes people human, alongside withthe spiritual life. It also requires ahealthy environment, one that ispeaceful, in which all people mayprosper, where tolerance is general-ized, and where violence is dimin-ished. Without this, we are all at agreater risk for ill mental health.

A vision for the future

■ Every individual will recognize theimportance of mental health.

■ Patients, families and communitieswill be more empowered for takingcare of their mental health needs.

■ Health professionals will becomemore skilled in prevention andtreatment of mental illnesses aswell as the promotion of mentalhealth.

■ Policy makers will be betterequipped to plan services morerationally and ethically.

Everyone can help

Individuals

■ Encourage wholesome earlyattachments and the acquiring ofage appropriate abilities in children.

■ Seek help if you have a mentalhealth problem or think you havesymptoms.

■ Join in efforts to dispel the mythsabout mental illness and brain dis-orders.

Families

■ In a crisis, involve all family mem-bers to solve the issue and supporteach other emotionally.

■ Recognize early symptoms andencourage family members to seekhelp if needed.

■ Support those suffering and do notdismiss their symptoms. Integratethem in the life of the family andthe community.

■ Join with other families to supporteach other and change commonmisconceptions.

We can do better Stop exclusionDare to care

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Medical professionals

■ Consider your patients’ emotionalstate as well as their physical state.

■ Seek out training to recognizesymptoms and acquire skills to carefor those with a disorder.

■ Involve the families in caring forthe patient.

Policy makers(governments and insurers)

■ Mental health is influenced bysocial factors; ensure that policiesextend beyond the mental healthcare system to include education,labor, criminal justice and generalhealth care systems.

■ Provide coverage to assume thecosts of mental health care as abasic guarantee.

■ Allot funds for mental healthresearch.

Science

■ Study, in a comprehensive manner,all factors, including genes, envi-ronment and behaviour that con-tribute to the cause and duration ofmental and brain disorders.

Mental Health professional associations

■ Advocate for care to be providedequitably and in the most optimalconditions.

Media

■ Contribute to empowering com-munities by reporting pertinentinformation and avoiding stereo-types and sensationalism.

■ Focus on human rights of mentallyill persons.

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NGOs

■ Educate the public about mentalhealth and disorders.

■ Organize support groups for fami-lies of the ill individuals.

■ Mobilize public opinion about poli-cies, programmes and welfare ben-efits for the mentally ill.

Communities

■ Create educational opportunitiesfor citizens to learn the importanceof mental health.

■ Teach children tolerance to differ-ences in individuals and acceptanceof disabilities.

■ Integrate those who have a mentalhealth problem by providing theman opportunity to best contributeto society.

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W H E R E T O L E A R N M O R E

The WHO World Health Report whichis focusing on mental illness and somebrain disorders will be available inJune 2001. The Report will providemore substance to the issues whichhave been highlighted in thisbrochure.

Addresses of WHORegional Offices

AfricaWHOParirenyatwa HospitalP.O. Box BE 773Harare Zimbabwe

Tel: (+263) 407 69 51 Fax: (+263) 479 01 46

Americas

WHO525, 23rd Street, N.W.Washington, DC 20037 USA

Tel: (+1-202) 974 30 00 Fax: (+1-202) 974 36 63

Europe

WHOScherfigsvejDK-2100 Copenhagen 0Denmark

Tel: (+45-39) 17 17 17 Fax: (+45-39) 17 18 18

Eastern Mediterranean

WHO Post OfficeAbdul Razzak Al Sanhouri Street,(opposite Children's Library)Nasr CityCairo 11371Egypt

Tel: (+202) 670 25 35 Fax: (+202) 670 24 92

South East Asia

WHOWorld Health HouseIndraprastha EstateMahatma Gandhi RoadNew Delhi 110002India

Tel: (+91-11) 331 78 04 Fax: (+91-11) 331 86 07

West Pacific

WHOP.O. Box 29321000 ManilaPhilippines

Tel: (+632) 528 80 01 Fax: (+632) 521 10 36

Many non-governmental organiza-tions are making a difference inimproving mental health care andreducing exclusion. They are toonumerous to list in this brochure. Visitthe website www.who.int/world-health-day for links to many of theseorganizations.

For moreinformation


Bridge the gap

Copyright © 2000 World Health Organization

This document is not a formal publication of the World HealthOrganization (WHO), and all rights are reserved by the Organization. The

document may, however, be freely reviewed, abstracted, reproduced ortranslated, in part or in whole, but not for sale or for use in conjunction

with commercial purposes.The views expressed in the document bynamed authors are solely the responsibility of those authors.

Concept and layout: Tushita Bosonet; logo: Marc Bizet

A product of NMH Communications

Health, as defined in the

WHO Constitution, is a state of

complete physical, mental and

social well-being and not merely

the absence of disease or infirmity.

World Health OrganizationDepartment of Mental Health and Substance Dependence

Avenue Appia 201211 Geneva 27

SwitzerlandTel:+41 22 791 21 11Fax:+41 22 791 41 60E-mail: [email protected]

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