When the editors suggested that I should write about psychiatry in developed and developing countries in the past 50 years I thought that they might have made the title shorter, say, call it ‘Psychiatry worldwide’, or ‘Psychiatry, its development and perspectives’: yet when thinking about it some more I felt that the title should be left as it is because it reminds us that many of the developing countries have parts that are highly developed and most of the countries that consider themselves highly developed have parts which are similar to the poorest of developing countries. The distinction between the two types of countries is not categorical but dimensional. Countries differ in the proportion of their populations that is poor because there are poor people everywhere. It makes no sense to propose solutions for developed and other solutions for the developing countries: solutions should refer to specific problems, not to countries in which the problems are to be solved. Clearly, the application of the solution will depend on the local circumstances and on the environment in which the problem exist; however, that does not imply that the solutions to problems should be different from one another. Once this principle is accepted it will be easier to learn from each other and to use the experience of others in building one’s health services or other parts of societies’ structures. This also makes it easier to collaborate in searching ways that can improve the lot of people with mental illness and their families worldwide.
The acceptance of this point of view means that it is not, for example, justified to propose the use of different medications (or other health interventions) for one set of countries but not for the other. It might well be that a medication that is most effective in dealing with a disease and causes least side effects is of such a price that the person who needs it cannot buy it: this should launch us on a campaign that will make the drug cheaper or reimbursable by the government or insurance companies, rather than proposing that the patient should receive a cheaper yet less effective medication or a medication with serious side effects because his country is classified as being poor. The example of the fight for affordable medication to treat AIDS showed the former course is possible and better than the decision to select less appropriate treatments.
Most of the recommendations for mental health policies and programmes in the ‘developing’ countries have been based on the latter strategy. The logics is that ‘developing’ countries have few resources and that therefore mental health services should use the cheapest medications or other interventions regardless of whether they are also the best for the diseases for which they are prescribed. This is not regarded as a temporary solution, but a reasonable and acceptable approach often embedded into the policies governing health care. A related message was that solutions lie in a better use of available resources rather than in the search for additional resources. This might well be true in some instances, but not in many others. What is worse is that in the field of mental health such a strategy contains the meta-message that mentally ill people are of little or no value to society or to themselves, thereby justifying second-best solutions—as long as they are cheaper. This meta-message is a strong confirmation of the content of the stigma that is attached to mental illness, suggesting that persons with a mental illness are of no value, incurable and in addition difficult, dangerous, and lazy. It also confirms the stigma attached to people in the developing countries implying they are less educated, less intelligent, less able to create or live in a civic society, unaware or dismissive of ethical principles—in short, less valuable or worthy of investment. It is of course true that in precarious situations it is better to use less effective interventions than none, and that lives can often be saved with second- or third-best interventions, even though they may have a high cost in terms of significant side effects. However, the use of less than best interventions and strategies should at all times be seen as a temporary surrogate of what is needed and understood as the best practice.
Recent years have seen major socioeconomic changes with considerable potential impact on mental health and the treatment of mental illness (1). Globalization, for example, can impose significant change in the value systems of countries participating in the global exchange. In part this is due to the fact that the flow of information between countries is not balanced; richer countries with highly developed technology send more information than they receive, influence more than they are influenced. Value systems prevalent in some European countries and the United States are being promoted (and imposed) in developing countries with the argument that they are more likely to make societies better, although the evidence for this statement is lacking. The striving for independence and autonomy of the individual, for example, is often presented as being preferable to accepting the interdependence of individuals living as a group. Clearly neither independence nor interdependence alone can make societies a safer and better place to live. A judicious mix of the two would be ethically and practically the best: unfortunately the defenders of the two stances are entrenched in their opinion and use extreme examples of the application of the opponent’s’ views to promote their ideas.
Another change relevant to psychiatry and the provision of mental health care is the trend of ‘commodification’ promoted by, among others, the World Bank and many governments. Commodification describes the tendency to handle all of the services and transactions in societies in economic and financial terms as if they were a commodity. Health care, for example, should be organized in a manner that will ensure a profit to the agency or government that is providing it. The position is rejected that helping feeble members of one’s society—children, elderly people, those with disabilities—is an ethical imperative of civilized societies. The economic imperative requires that help should be provided in a manner that will bring measurable and immediate economic benefits to society, particularly in terms of increased productivity. A reflection of this trend is also the abandonment of the terms ‘least developed’, ‘developing’, and ‘developed’ countries which are now referred to as ‘low income’, ‘middle income’ and ‘high income’ countries.
Changes in sociodemographic structure over the past several decades have also greatly influenced psychiatry. For example, the change of age distribution in many societies has increased the prevalence of geriatric mental disorders, and the diminution of the size of the family in most countries has reduced their capacity to look after chronically ill members.
Most societies are also experiencing changes of the size of their middle class. In developing countries it has grown exponentially, thus creating a large market for health and related industries; the growing middle class already attracted a strong private health care sector, developed within the country or imported from abroad. The urgency to strengthen primary health care has diminished in parallel with this development, although the governments continue to emphasize the need to build it up The upward-striving members of the middle class want to be treated by the most qualified and famous specialists (and now can afford this); they do not want nurses and general practitioners as their main care providers; they do not want the kind of care that they see as being for the poor who cannot afford better.
In many settings policies and recommendations about primary health care are not supported by a commensurate increase in the budget. The emergence of ‘specialized’ primary health care—i.e. the placement of specialists’ services as the first point of contact—also belies the original intentions of the primary health care agreement embodied in the Alma Ata declaration (and report) on primary health care (2,3). Other changes of the social structure, such as those caused by diminishing natality and increased rates of divorce, are not universal but exert a powerful impact on health care in the countries where they exist.
Finally, another massive social change derives from migration—economic, voluntary, or forced—from rural to urban areas and from country to country. The impact of migration on mental health varies with the manner in which it took place. In some instances candidates for migration are screened by medical authorities to exclude those with an illness. The consequence of this procedure, currently in place in a variety of countries, is that the migrants generally have fewer diseases than the host population while the prevalence of diseases in the donor country increases. Refugees, on the other hand, often have higher rates of mental disorders than the host population—a finding that is particularly striking in instances in which the rules forbid repatriation if the refugees are mentally or physically ill.
This volume contains fine descriptions of developments that have had a significant impact on psychiatry and its application over the past 60 years. These include the rise of psychopharmacology, the development of powerful neuroimaging methods, the production of a multitude of standardized diagnostic procedures, the revolutionary advances of genetics, and the discoveries of other basic sciences. Most of these discoveries have opened the door to further research and scientific advances; however, the stark reality is that they have not significantly affected the provision of services to the mentally ill. Other developments—such as those mentioned in the introduction—had an impact on the practice of psychiatry and eroded several of the paradigms on which its practice is based. The formulation of new paradigms that are more harmonious with the environment in which mental illness occurs, and in which treatment takes place, is not likely to be difficult. What will represent a major challenge will be to demonstrate to all who hold current or past paradigms sacred that they must abandon them and accept their change or substitution. The following pages will examine six such paradigms and propose components that could be used in reformulating them.
The first of these paradigms concerns the site of psychiatric treatment. In the late 19th and early 20th century most of the industrially developed countries erected large mental hospitals. Those that had colonies did the same in many of these locations. Psychiatric treatment at that time included a variety of interventions, most of them based on the opinion of the leading psychiatrists rather than on evidence about their effectiveness. Some of these treatments were based on the notion that severe stress might bring the patients to their senses—a rationale resembling that used with crackling old radios which, when hit, sometimes had an improved sound. Patients were immersed in cold water, exposed to conditions of sensory deprivation, placed in turning cages (4,5). Less drastic treatments were also employed—patients were taken for walks in the parks, made to listen to gentle and harmonious music. Treatments which involved infection with malaria, search for sources of ‘focal sepsis’ with a consequent surgical removal of those sources (6), insulin coma treatment, leucotomies and lobotomies, treatment with special diets, and various convulsive therapies all had their time; a common denominator to all these efforts was that they were usually performed in mental hospitals. Some of these were huge, like the Pilgrim State Hospital in the state of New York, USA (with more than 13,000 patients and several thousand staff), some small, some private, some managed by the government. The smaller private hospitals were often run by a psychiatrist who employed members of his family as key personnel in the institution.
The mental hospitals built in colonial times in developing countries resembled those in the industrialized world. Practically all of the funds that the government was providing for mental health care had to be used to maintain the hospitals. The funds provided to the hospitals were, however, insufficient to maintain the buildings, to ensure regular clean water supply and the elimination of waste, to maintain the parks that often surrounded them, and to pay decent salaries to hospital staff. Even when the funds given to the hospital were substantial, their use frequently lacked any form of effective control and tended to be left in the hands of the hospital directors who were not necessarily skilled managers. The result of underfunding and poor management of institutions—which were usually far away from the public eye—was the physical deterioration of the facilities, loss of staff, and a continuously lessening quality of care. The abuse of hospitalized patients was a frequent occurrence, often not reported. There were no systems in place to ensure that patients would get appropriate treatment or be protected against abuses of their human rights.
In the middle of the 20th century the idea of providing treatment to patients living in the community gained ground. Communities were to accept people with mental illness as their members and support their families or other carers. Mental hospital beds were to be reduced to a minimum. Inpatient and outpatient services were to be placed in the institutions providing general health care. Governments were easily persuaded by the advocates of community psychiatry who often claimed that the reform of mental health care arrangements would reduce the cost of care as well as improve the quality of life of the mentally ill. In some countries the reduction of beds was drastic—in the United States, for example, several hundred thousand beds were eliminated and in Italy the parliament passed a law by which all state mental hospitals had to be abruptly closed, without delay. In other countries the reduction of the numbers of beds was slower but the goal of reducing the size of mental health institutions was accepted by most professionals and by the governments.
As time went by and the experience of closing inpatient facilities grew, several facts emerged. First, the transition of inpatient facilities to a community mental health care system did not reduce the cost of care; in fact, while the transition was under way the cost of care was increased because it was also necessary to maintain the hospital in operation during the period of transfer. Subsequently, well-run community services seemed to be just as expensive as hospital care (and sometimes more so). When settled in the community patients reported an improvement of their quality of life, but the symptoms of chronic mental illness did not change very much (7).
In other settings, where the transition from hospital care to community care was more abrupt, and where the investment into the development of appropriate mental health services in the community did not occur, patients’ conditions often deteriorated and many of them—now that the treatment facilities were reduced in size—ended up in prison (8,9). Thus, deinstitutionalization, the goal of the reformers, turned into transinstitutionalization—from hospital to prison—offering a considerably less appropriate environment for the many incarcerated mentally ill.
Another fact that emerged was that the capacity of the family to look after the mentally ill was constantly diminishing. This was due to the gradual disappearance of the multilayer extended family that could cope with the burden of care for a chronically ill member. Nuclear one-tier families could not provide care for a person with mental illness without external help, particularly in settings in which women also accepted or sought work outside the house.
In addition, there was the difficulty of transferring staff from the hospital to the community, problematic because of the reluctance of personnel to work in a community setting and the need to retrain many who were trained for work in hospital and only had experience of care provided to inpatients—a retraining that required considerable additional resources. These problems were present in developed countries which were introducing community care. In developing countries that also made attempts to introduce community care it was not easy to overcome prejudice and tradition or to find funds to support change. Islands of such care were sometimes created by gifted leaders: but what they built usually did not survive their departure.
For all these reasons the paradigm of community care will have to be reformulated. If community care is to be successful it will be necessary to invest additional resources into the development of health services in the community; staff recruited to work in the mental health services will have to be aware that their place of work will be in the community; a certain number of beds will have to be maintained to provide care to patients who require hospital care, and the facilities in which they will be placed will have to be covered by arrangements for quality assurance; families and other carers will require substantial help in terms of appropriate financial aid, additional education, and moral support; outreach qualified services, which have demonstrated their value in various settings, will have to be added to the community mental health services; and collaborative arrangements will have to be developed with institutions caring for people with mental illness who also have physical illnesses, and those living in institutions such as care homes and prisons. In addition it will be necessary to have inpatient and outpatient facilities that can provide emergency services to people with mental illness and deal with acute and incipient mental disorders.
The realization of such an array of services will take time and at present might not be feasible in many places. Nevertheless, in terms of quality and components of mental health services it is a model of this kind that has to be seen as the necessary goal for both developing and developed countries. The original paradigm of total or nearly total transfer of responsibility for the mentally ill to the community has to be significantly reformulated. Recent publications seem to indicate that these changes of community care paradigms are beginning to be recognized (10).
Some 40 years ago an Expert Committee of the World Health Organization (WHO) considered strategies that could be employed to extend mental health care to those in need of it (11). It recommended that personnel employed in primary health care services should be given additional training that would enable them to recognize the most severe forms of mental disorders and provide appropriate treatment. The Expert Committee’s recommendation was not a total novelty; the idea that tasks related to mental health should be undertaken at general and primary health care level had been voiced by experts on previous occasions and as early as in 1871 by Isaac Ray (12), but it was felt that a report by a prestigious WHO Expert Committee would give that notion additional weight and facilitate its promotion. In the years that followed, WHO carried out a multicentre study to explore whether the recommendation could be realized. Investigators in Senegal, Colombia, India, and the Philippines participated in the study, which demonstrated that short training courses can teach primary care staff how to recognize and treat ‘priority conditions’—including serious mental and neurological disorders such as schizophrenia and epilepsy (11,13). Publication of data obtained in this study was then used to promote the idea of shifting the tasks related to the recognition and treatment of mental health problems from psychiatrists and mental health services to simply trained staff and general health care services. The paradigm of task shifting seemed well-formulated and the hope was that health services would provide care to people with serious mental illness.
The formulation of the paradigm did not lead to significant changes of practice. While the usefulness of the strategy could be demonstrated in well-selected areas, with strong leaders, national recognition, and external support (such as recognition and support by WHO) the work in pilot study areas could not be generalized and implanted in other areas without additional resources or outstanding leaders keen to see the project work (14). When external support ceases, the new community care model withers away—an experience reported from many countries over the years. In the first decade of the 21st century WHO had to state, regretfully, that the gap between needs for mental health care and its actual provision has grown, and that a vast number of people with serious mental illness in developing countries do not receive necessary treatment. A new WHO programme, ‘Mental Health Gap Action Programme’, has been launched to reduce this gap (15) and it is to be hoped that it will be successful.
Nevertheless, there are good reasons to reconsider the value of the ‘task shifting’ paradigm. Doctors and other staff working in general health care services are often reluctant to accept tasks related to the care of mental disorders. Sometimes this can be overcome by adding an incentive, for example the financial incentives offered to general practitioners (GPs) in the United Kingdom who are regularly using depression screening questionnaires. But often the willingness to deal with mental disorders stops once they are recognized, resulting in referral to a mental health service. Courses given to GPs and other health care staff in developed and developing countries often show no effect in terms of practice change (16). A vast majority of general health care personnel have received only rudimentary training about mental health in their basic education and often share the negative and discriminatory opinion of the general public about the mentally ill.
A reformulation of the task shifting paradigm might include the following elements. First, training about the recognition and management of mental disorders should only be offered to general health care personnel who are interested in such learning. Second, the training should not be a systematic education about all psychiatric disorders, but address specific frequently encountered problems giving their solution (e.g. on the recognition and treatment of depression). The modules should be deliverable in a short course (possibly one half-day duration) because GPs often find it impossible to stay away from their practice for very long. Third, the courses should not be given by mental health specialists but by well-informed general health workers of the same level (e.g. a nurse trainer for nurses, a GP teacher for GPs) with a mental health specialist as a resource person present and willing to give advice and guidance when asked to do so. Fourth, teaching should not focus exclusively on the recognition of conditions, but rather the provision of skills necessary for the delivery of interventions by the trainees. The above-listed elements might help to shift the responsibility for some of the mental health tasks to non-mental-health personnel, though much of the responsibility of the management of severe and complex mental disorders is likely to remain with specialized personnel and a well-organized care system. This in turn means that the training and employment of mental health personnel remains important and cannot be circumvented by shifting tasks to other categories of personnel.
The notion of task shifting is closely related to the paradigm of primacy of primary health care, which states that emphasis of health service development should be on strengthening primary health care even if this means relative neglect of specialized services and a decreased priority for basic or applied scientific work. The origin of that paradigm can probably be traced back to the years after World War II during which simple interventions—such as spraying with insecticides which could be done by untrained workers—saved lives of millions of people from malaria, typhus, and other insect-borne diseases. In remote regions of the Soviet Union, for example, simply trained staff known as feldschers proved their worth in the years that followed World War I and subsequently did very well dealing with the prevention of communicable diseases, introducing hygienic measures and health education, and providing first aid to the wounded. In some other countries similarly trained personnel (e.g. the ‘barefoot doctors’ of China) helped decrease morbidity and mortality from illness. Similar schemes were put into operation in various other countries and reports of these successes in China, Cuba, Guatemala, India, Indonesia, Niger, Tanzania, and Venezuela published in 1975 (17) prepared the ground for a meeting of Ministers of Health and numerous experts in Alma Ata in 1978. The Alma Ata conference produced a report and a declaration listing the 10 essential ingredients of primary health care. The declaration and the report stated a number of principles that should govern the organization of primary health care (2). Most of these were ethical desiderata which could be used to strengthen the case for the introduction of mental health programmes and could serve as a boost for psychiatrists (18). The definition of primary health care, however, contained also the phrase that primary health care should include elements which ‘… the countries can afford’, allowing countries to do little about primary health care if they decided that they ‘could not afford’ to introduce it.
At this point WHO and governments in most countries viewed primary health care as the answer to the world’s health problems. Many drafted health policies based on primary health care principles, and made significant efforts to reform the health care system so as to be congruous with the principles of the Alma Ata declaration. As could be expected, it was easier to draft policies than to implement them, and the follow-up of the Alma Ata declaration was in many places reduced to lip service to the principles it announced.
While the notion of strengthening primary health care has significant merit it also has a dark side, namely reducing support to the development of specialized health care. This was particularly harmful for disciplines that were largely ignored previously and because of this policy became even more retarded in their development. Pediatrics, despite its obvious importance in a world in which half the population consists of children and adolescents, was one of the neglected disciplines. Psychiatry was in a similar situation. In both instances neglect of the specialty reduced the possibility of enhancing knowledge and translating it into tools for use in primary and general health care.
The changes of opinions and attitudes relating to leprosy, tuberculosis, and sexually transmitted diseases are examples of the destigmatization of diseases that occurs when an effective treatment has been discovered and applied. It was the hope of many decision-makers, social scientists, and mental health specialists that the same would happen with mental disorders. Good treatment would lead to a reconstitution of mental functions (and thus the disappearance of reasons for the stigma) and make people with mental disorders acceptable by society.
This paradigm continues to have defenders, although stigma of mental illness persists despite the range of effective, or partially effective, treatments that have emerged in the past six decades. While cognitive therapy and pharmacotherapy may not be perfect, they are now available as routine treatment options in developed countries. Medications prescribed to the mentally ill are better (in terms of reduction of symptoms and prevention of relapses) than medications for the treatment of various physical illnesses that are not stigmatized (19). Nevertheless, the stigma of mental disorders has not diminished, and may even be more pronounced. Recent reports indicate that people with mental illness experience stigmatization in all walks of life and are additionally burdened with self-stigmatization (20,21). The reasons for failure of this expectation and of the paradigm based on it are not well understood, but seem to include a number of factors. Psychiatrists have still not arrived at a consensus about the best ways of treating mental illness. Schools of psychiatry argue publicly against treatments whose effectiveness they question and, consequently, diminish the credibility of the specialty of psychiatry and its armamentarium. Some treatments appropriate for specific psychiatric disorders have been used too widely. Their inappropriate use not only failed to help patients and harmed some of them but also reduced faith that the treatment offered by psychiatrists was effective. Another reason for the persistence of stigma despite effective treatments is the reluctance of patients with mental illness to disclose information about their illness or to talk about its treatments, regardless of whether it was effective or not. The good news about the effective treatment of mental illness is thus not spread by people who experienced it, a situation very different from that in the field of physical illness and its treatment. While a surgical intervention leading to recovery from a potentially lethal illness is usually widely praised by fortunate patients, a parallel scenario has only recently become a reality in psychiatry. At last, there is an increasing number of testimonies from well-known people—such as the prime minister of Norway—who now discuss their mental illness and its successful treatment. Unfortunately, on the other hand, the failures of mental health treatments—confirming a previously widespread prejudice—seem to be of far more interest to the media than their successes.
Among reasons for the failure of the paradigm could also be the well-organized antipsychiatric propaganda by groups such as the Church of Scientology and the recent actions of producers of psychotropic medications. The latter have, in recent years, adopted the strategy of pointing out the weaknesses or side effects of the competitors’ drugs in order to sell their own. As a result, the credibility of all medications used in psychiatry has been diminished and the prevailing opinion about them in the mind of the general public, and health workers in the fields other than psychiatry, is that they are unlikely to help and are often harmful. A further consequence of the image of dangerousness of psychotropic mediations is that GPs and specialists in other branches prescribe psychotropic drugs in doses far too low to achieve an effect, which contributes to their poor opinion about these drugs. An institutionalized example of this tendency is the recommendation of a nursing association about the treatment of depression—to treat it by giving patients a non-therapeutic dose of an antidepressant.
The paradigm of destigmatization by the demonstration that psychiatric disorders can be successfully treated could still be saved if all those involved—patients, their families, psychiatrists, and other health care workers—were to place more emphasis on presenting the positive outcomes of psychiatric treatment in a realistic manner. While admitting weaknesses, they should highlight and assemble evidence as a basis for a consensus about the best treatment for specific mental disorders. This will not remove all stigma, but is likely to diminish it.
The 1960s were marked by a growth of interest in public health aspects of psychiatry—a development that seems to have stemmed from vestiges of military medicine which was successfully using mass approaches to the promotion of health during World War II and in the decade that followed it. This interest found its expression in the increasing number of epidemiological studies of mental disorders, in the strengthening of the involvement of schools of public health in mental health, in the creation of nongovernmental organizations focusing on mental health (rather than mental disorders), and in studies of functioning of mental health services. Gradually, the emphasis has moved to the study of specific diseases using biological methods and to issues related to the treatment of mental illness—both probably related to the introduction of new psychopharmacological agents in the treatment of mental disorders. Chlorpromazine and similar medications and, somewhat later, antidepressants, seemed to open the door to a psychiatry practised in a manner similar to other branches of medicine. Initially this new psychopharmacotherapy targeted symptoms; somewhat later, the indications for treatment were defined in terms of disorders. Many educational guidelines for practice described what needs to be done to recognize and manage specific disorders At the same time the general advances of medicine and the reduction of morbidity from communicable diseases gradually led to the disappearance of physical disease wards (for tuberculosis, cerebral malaria, encephalitis, etc.) that had been obligatory parts of mental hospitals until then. This trend contributed to the tendency to neglect comorbid physical illness in psychiatric practice. The neglect of comorbidity of mental and physical illness also reflected, in part, the traditional and enduring separation of psychiatry from other medical disciplines.
The descriptions of mental disorders in textbooks of psychiatry give an impression that diseases appear one by one: the notion that the form, treatment, and outcome of a disorder depend on what other conditions might be present received very little attention. The biopsychosocial approach introduced by Engel in the mid-1970s argued that psychological, biological, and social factors play a role in health and disease: but despite the apparent comprehensiveness of this approach the focus of much research and service development remained based on the paradigm of single-disease morbidity. Problem-based education introduced in some of the medical schools in the late 20th century did expect students to look at patients in their entirety; yet in most instances psychiatric problems were conspicuous by their absence in the descriptions of problems that were used in such training.
The neglect of comorbidity of mental and physical illness is harmful for patients, whether their ‘primary’ illness is physical or mental, and for the discipline of psychiatry. The prevalence of comorbidity grows with age but it is present at all ages. It is now becoming closer to a rule rather than an exception. Yet psychiatrists seem to focus their attention on the comorbidity of mental disorders (to a large extent an artefact of the currently existing classification rules) and are reluctant to look for illnesses that are not their specialty. Specialists in other disciplines do the same, with consequent poorer outcome of treatment and a greater frequency of complications in the course of treatment (22–28). The single-disease paradigm needs to be discarded and replaced by a comorbidity paradigm. Findings of research in recent years indicate the high (and growing) prevalence of comorbidity, and experience from practice shows that a comprehensive approach covering all the diseases that a person might have at the same time is necessary. It is clear that the appropriate management of comorbidity will require major changes in the organization of services for people with mental illness and in the education of all types of health personnel. This is a challenge for governments but also for specialists of all types—a challenge that has to be met at a time when comorbidity is becoming more frequent, and while medicine is increasingly fragmented. For psychiatry this reorientation will be beneficial—not only because it will make it possible to provide better care to people with mental illness but also because a change of its practice will bring it back to other branches of medicine from which it has been separated for a long time—to the loss of both medicine and psychiatry.
People with mental illness are disadvantaged in many ways. Stigmatization prevents their access to housing, employment, and social activities. The stigma of mental illness implies that people suffering from mental illness are of no value to society and that they will not recover from their illness. Medications which are used in the treatment for mental illness are wrongly considered to be very expensive (and governments are reluctant to provide them) although there are many other types of medications (e.g. medications used in the treatment of cancer) that are much more costly yet do not have the reputation of expensiveness. In many countries—including the United States until very recently—the treatment of mental illness is reimbursed less well than treatment for other diseases. Schooling for children with intellectual impairments is less well supported than schooling for children who suffer from other types of disability. The reimbursement for a day of treatment in a psychiatric institution is lower than that for other diseases. It is therefore not surprising that one of the paradigms of health care for the mentally ill today is that governments and insurance companies should introduce parity of care for people suffering from mental and other diseases. Parity in terms of reimbursement for treatment has been considered an important principle and achieving parity continues to be a goal of a number of non-governmental organizations.
Yet, that paradigm has also been gradually eroded. People with mental illness are often poor and less well educated than their peers. They frequently have few social skills and their families are more likely to be dysfunctional. Their knowledge of the law and of the regulations that govern health care are usually non-existent. Thus, even when equal access to health care is guaranteed by law and when services are available, people with mental illness will use them less well than people who have other illnesses. In addition the very symptoms of mental illness—and previous experience, sometimes of coercion and abusive treatment, in contact with health services—make many of those suffering from mental disorders reluctant to come forward and ask for help.
It follows that aiming at equal access to care is not enough: mental health services must have additional means to provide care and the goal should no longer be equal access to care (29)—but care sufficient in quality and quantity to arrive at the best possible outcome. This replacement of the paradigm of parity by a paradigm of sufficient care (or a paradigm of equal outcome) will require legislative and other action—but the first step should undoubtedly be the acceptance of the fact that the goal that was pursued with so much vigour in many places is not sufficient to offer an equitable model of health care.
Public health is inseparable from politics, and nowhere is this truer than in mental health. For example, the cold war between the United States and the Soviet Union (and their respective allies) found its reflection in the definition of the legitimate area of psychiatry and of its methods of work. The emphasis on the biological origin of mental disorders and treatment using ‘biological methods’ was the accepted doctrine of treatment in the Soviet Union and its satellites, while psychoanalysis and other psychodynamic approaches predominated in the United States and Western Europe. In parallel with this difference of opinion was also the difference in the definition of the legitimate tasks of psychiatry. The prevention of mental disorders and the promotion of mental health were seen as essential components of psychiatry and mental health sciences in the West; in eastern Europe the promotion of mental health was seen as a task of the government whose duty was to create a health-promoting environment and to provide regulations that will optimize the physical, mental, and social development of the citizens and make them live a life of good quality. The difference between the Eastern and Western blocks also found its expression in the definitions of quality of life. In the Soviet zone of influence quality of life was defined as the satisfaction of (mainly material) human needs—such as shelter, food, health care—while on the other side of the Iron Curtain the definition emphasized the feelings of the individual whose quality of life was assessed, rather than the degree to which the human needs were met. Thus, for the Western scientists it was important to assess whether an individual is happy to have (or not have) a job, not only whether he has one. Some of the human rights were also interpreted differently, Thus, for example the right to work was interpreted in the Eastern block as the obligation of the state to provide jobs for everyone; in the Western block the right to work was interpreted as the right to be considered for a job and get it if qualified and if there is a job available.
The difference in the definition of psychiatry as a discipline was further confounded by the differences in the definition of the promotion of mental health. While the Western countries considered that promotion of mental health is best seen as an increase of the value that people give to their mental health, in the Eastern block the promotion of health meant a decrease of the prevalence and incidence of mental diseases.
Worldwide the prevention of mental and neurological disorders was given relatively little attention and the prevailing opinion was that little can be done to prevent these disorders. A notable exception to this position was the sterilization of the mentally ill in a number of countries, but this practice was gradually abandoned, particularly after the horrors perpetrated in this respect in Nazi Germany. Various other practices were supposed to prevent dysfunctionality of families and consequent higher risks for mental disorders in children, but there was little consensus about the best measures to take and little evidence that such interventions were useful.
In time it became accepted that most of the prevention of mental disorders cannot be the sole responsibility of mental health services, but rests mainly with other parts of the health and social system. In the 1980s a report to the World Health Assembly of WHO summarized possibilities for prevention of mental disorders (30–32). The report and its recommendations were well accepted by governments and a follow-up 2 years later indicated that some action was taken. The report drew attention to a variety of measures which could significantly reduce the incidence of mental and neurological disorders, including the provision of adequate perinatal care, prevention of brain injury by the obligatory use of helmets by cyclists and motorcyclists, provision of iodine to women before and during pregnancy, education of parents, arrangements for the education of children with intellectual impairments, correction of sensory deficits (e.g. of vision) and others—all with fairly good evidence of effectiveness. More recently a variety of other measures have been tested and recommended. The paradigm of responsibility of psychiatry for the promotion of mental health and the prevention of mental disorders will thus also need to be reformulated. Psychiatry can recommend measures and interventions to prevent brain injury and other risks to mental health, but the responsibility for the application of these measures has to be with the general health care and social service system. The promotion of mental health, in the sense of raising the value that people give to mental health, must also be the responsibility of other social agents such as schools, producers of educational media, parent organizations, and social services The formulation of legal instruments that will support the promotion of mental health and the prevention of mental illness will remain the area of responsibility of governments. Psychiatry can at best identify risk factors that may lead to mental disorder and draw attention to them so that appropriate action can be taken.
The past 50 years have been rich in events and developments that have affected psychiatry in developing and developed countries. Science has produced new knowledge about the functioning of the brain and put in place new methods of investigating its function. Psychopharmacology has created effective medications that can be used in the provision of mental health care. New and effective methods of psychotherapy (such as cognitive behavioural and interpersonal psychotherapy) have been introduced and it has been demonstrated that they can be used with significant effect in different social and cultural settings. The doors have thus been opened to further scientific investigations and to a major change in the practice of psychiatry.
These and other scientific and medical developments have been happening in the context of major changes affecting the world’s societies. Among them, globalization, emphasis on economic productivity at the cost of social and cultural progress, rural–urban and intercountry migration, and changes of demographic structure of societies have been particularly important for psychiatry and its applications. They have led to an erosion of some of the paradigms on which psychiatry and mental health services have been based. Emphasis on community care, on parity of access to mental health services, and on shifting of tasks from specialized to general health services are among paradigms that need to be reviewed and revised—as well as those that emphasize single-disease morbidity in psychiatric practice and teaching and the primacy of primary health care.
It is clear that optimal approaches to mental health service development will not be immediately possible in all settings and that they may have to be somewhat adapted to fit local conditions. Yet, in contrast to what happens today, the inability (or reluctance) to immediately introduce the optimal solution would not lead to the acceptance of second-rate, suboptimal solutions but to efforts to make the application of the best possible. In a vast majority of countries the introduction of the correct answer to mental health problems is a matter of moving resources from one budgetary line to another; in some countries—and their number is very small—external help is necessary and could be requested on humanitarian and scientific grounds. An essential step in this strategy is to do whatever is possible to arrive at a consensus about the optimal solutions to mental health problems and disorders based on evidence and experience, and involving all concerned—the psychiatrists, other mental health workers, the mentally ill and their families, and general health care workers. It is to be hoped that reaching that consensus (which psychiatry has not even attempted to do so far) will be recognized as a priority for the further development of mental health care and psychiatry worldwide.
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