BETTER UNDERSTANDING APPROPRIATE CARE IN MENTAL HEALTH
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World Health Organization
Regional Office for South-East Asia
WORLD
HEALTH
DAY
200 1
Mental Health
Better Understanding Appropriate Care
in Mental Health
Epilepsy: Social Consequences and Economic Aspects
Page 1 of 4
Fact Sheet N°166
Revised February 2001
EPILEPSY: SOCIAL CONSEQUENCES AND
ECONOMIC ASPECTS
SOCIAL IMPLICATIONS
Fear, misunderstanding and the resulting social stigma and
discrimination surrounding epilepsy often force people with this
disorder "into the shadows". The social effects may vary from country
to country and culture to culture, but it is clear that all over the world
the social consequences of epilepsy are often more difficult to
overcome than the seizures themselves.
Significant problems are often experienced by people with epilepsy in
the areas of personal relationships and, sometimes, legislation. These
problems may in turn undermine the treatment of epilepsy.
Misunderstanding and Social Stigma
Some examples of misunderstandings about epilepsy from around the
world:
o In Cameroon it is believed that people with epilepsy are
inhabited by the devil. This does not mean that they are seen as
evil, but that evil invades them and causes them to convulse
from time to time.
• In China, epilepsy diminishes the prospect of marriage,
especially for women. A survey of public awareness in 1992
revealed that 72% of parents objected to their children marrying
someone with epilepsy.
• In some rural areas of India, attempts are made to exorcise evil
spirits from people with epilepsy by tying them to trees, beating
them, cutting a portion of hair from their head, squeezing lemon
and other juices onto their head and starving them.
• In Indonesia, epilepsy is often considered as a punishment from
unknown dark forces.
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• In Liberia, as in other African countries, the cause of epilepsy is
perceived as related to witchcraft or evil spirits.
• In Nepal, epilepsy is associated with weakness, possession by
an evil spirit or the reflection of a red colour. Bystanders who
witness a seizure will often spray water on the forehead of the
person experiencing the seizure of make him or her smell a
leather shoe.
• In the Netherlands in 1996, a person was whipped and put into
isolation because her seizures were thought to result from
magic.
• In Swaziland, many traditional healers mention sorcery as the
cause of epilepsy.
• In Uganda, as in many other countries, epilepsy is thought to be
contagious and so people with epilepsy are not allowed to join
the communal foodpot for fear of others contracting epilepsy
through that person’s saliva.
Legislation
In many countries legislation affecting people with epilepsy has
reflected centuries of suspicion and misunderstanding about epilepsy.
For example, people with epilepsy are often prevented from marrying
or having children:
• In both China and India, epilepsy is commonly viewed as a
reason for prohibiting or annulling marriages.
• In the United Kingdom, a law forbidding people with epilepsy to
marry was repealed only in 1970.
• In the United States of America (USA), many individual States
prohibited people with epilepsy from marrying. The last State to
repeal this law did so in 1980.
• In the In the United States of America (USA), 18 States provided
eugenic sterilisation of people with epilepsy until 1956. Until the
1970s, it was also legal to deny people with seizures access to
restaurants, theatres, recreational centres and other public
buildings.
Employment
Unemployment and underemployment exist worldwide, but more so
with people with epilepsy. The misunderstandings and stigma
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Epilepsy: Social Consequences and Economic Aspects
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mentioned previously are usually to blame for this. For instance:
• A survey in China showed that 31% of respondents believed that
people with epilepsy should not be employed.
• Data from Germany, Italy and USA indicate that people with
epilepsy of working age, 40%-60% are employed (although
these jobs are often below their potential), 15%-20% are
unemployed and about 20% retire early.
• In rural areas of India, people with epilepsy are generally looked
after by their families and they usually help with their family’s
trade, although this will be with fewer responsibilities and less
strenuous roles than "normal" people.
• In a recent research survey, nearly a quarter of Nepalese people
with epilepsy took the view that they were unable to work. As in
many countries, these people with epilepsy had been culturally
conditioned to underrate themselves.
Treatment
Misunderstandings about epilepsy, combined with the economic and
financial barriers to availability of treatment in developing countries,
play an important role in preventing treatment becoming available to
millions of people in developing countries. For example, culturally
informed health-seeking strategies often lead the majority of people
with epilepsy in developing countries to turn to traditional healers for
treatment.
Economic Aspects
• In 1990, WHO, identified that, on average, the cost of the anti epileptic drug phenobarbitone (which alone could be used to
control seizures in a substantial proportion of those with epilepsy
and which is on the WHO list of essential drugs) could be as low
as US$ 5 per person per annum.
• The World Bank report "Investing in Health" (1993) states that,
in 1990 epilepsy accounted for nearly 1% of the world’s disease
burden. Epilepsy commonly affects young people in the most
productive years of their lives, often leading to avoidable
unemployment.
KEY POINTS
• The cost and burden of epilepsy varies between countries.
• The anti-epileptic drug phenobarbitone can cost as little as US
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Epilepsy: Social Consequences and Economic Aspects
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$5/person/annum and can be used to treat many people with
epilepsy.
• People with epilepsy continually face social stigma and
exclusion. A fundamental part of ridding the world of this stigma
is to raise public and professional awareness.
• Legislation which reinforces fear and discrimination must also be
changed.
For further information, please contact the Office of the Spokesperson, WHO, Geneva. Tel: (+41 22) 791 2599.
Fax: (+41 22) 791 4858. E-mail: inf@who.int. All WHO Press Releases, Fact Sheets and Features as well as
other information on this subject can be obtained on Internet on the WHO home page http://www.who.int/
© WHO/OMS. 1998 I Concept
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Fact Sheet N°217
April 1999
THE 'NEWLY DEFINED' BURDEN
OF MENTAL PROBLEMS
Mental and neurological problems are among the most
significant contributors to the global burden of disease
•
Increasingly sophisticated methods to measure health and its burden, in
particular the DALY (Disability Adjusted Life Year), have helped to provide a
more balanced conception of the needs and priorities in the area of health for
both developing and developed countries.
What the DALY does is to quantify not only the number of deaths but also the impact
of premature death and disability on a population. It combines them into a single unit
of measurement of the overall burden of disease.
One DALY is one lost year of healthy life. As the table below shows, mental
problems accounted for approximately 10% of all DALYs lost in 1990. They are as
relevant in developing countries as in industrialized societies.
Health problems
% DALYS lost (1990)
Infectious and parasitic diseases
22.9
•Unintentional injuries
[Mental problems*
11.0
[Cardiovascular diseases
9.7
[Respiratory infections
[Perinatal conditions
6.7
Malignant neoplasms
5.1
10.5
8.5
‘Mental problems include unipolar and bipolar affective disorders, psychosis, epilepsy, dementia,
Parkinson's disease, multiple sclerosis, drug and alcohol dependence, post-traumatic stress
disorder, obsessive compulsive disorder, panic disorder, other neuropsychiatric disorders.
•
It is also of great significance that 5 of the 10 leading causes of disability
worldwide (major depression, schizophrenia, bipolar disorders, alcohol use,
obsessive compulsive disorders) are mental problems. They are as relevant
in developing countries as they are in industrialised societies
While there have been dramatic improvements in physical health in most countries,
particularly unprecedented improvements in mortality rates, the mental component
of health has not improved over the past 100 years. In fact, in many instances it has
deteriorated significantly.
Average life expectancy in
low income countries such as Democratic
2
Republic of Congo, Egypt and India have risen from 40 to 66 years, infant
mortality rates have plummeted, smallpox has been eradicated and many
other infectious diseases brought under stricter control.
•
In sharp contrast, mental, behavioural and'social health problems, involving
hundreds of millions of individuals, have become much bigger contributors to
the global health burden. That emerges clearly from the table below:
Mental problems and neurological
|
Number of cases (mi||ions)
disorders
(Major depressive disorders
340
Alcohol related problems
288
iMental retardation
60
[Epilepsy
40
(Dementia
(including
disease)
(Schizophrenia
Alzheimer's
29
45
[Attempted suicides
10-20
.'Completed suicides
1
Mental problems tend to proliferate as a result of complex, multiple biological,
psychological and social factors such as war, poverty and limited access to
resources.
Mental problems are experienced by those suffering from serious and/or chronic
'physical' diseases and from war and trauma. They exist even when the above
conditions are not present.
•
In most cases, a complex interaction process between biological,
psychological, and social factors contributes substantially to the development
of mental health and neurological problems.
•
Strong links have been made between mental health problems with a
biological base, such as depression and changes in social behaviour,
interpersonal support, personal coping, and adverse social conditions, such
as high unemployment, limited education, gender discrimination, human
rights violations, and poverty.
The future will bring an expotential increase in mental health problems
•
The burden of mental and neurological problems is likely to become even
heavier in the coming decades and will raise serious social and economic
obstacles to global development unless substantive action is taken.
.
Given the ageing of the population, exacerbating social problems and unrest
the burden of mental problems will grow substantially.
3
Specific reasons include: (1) increased life-expectancy of those with mental
disorders; (2) a larger number of people reaching young adulthood, leading to a
greater number of people developing schizophrenia; (3) a larger number of people
surviving into old age, adding to the greater number of people suffering from
dementia.
The incidence of depressive illness increases with age, and it is predicted that
depression will be the second leading cause of disease burden in 2020. This
is a sobering thought.
The rapidly rising numbers of persons affected by violent conflicts, civil wars
and disasters, and the growing number of displaced persons will contribute to
psycho-social problems and interpersonal violence within communities. Such
populations have been systematically shown to have increased rates of
mental disorders, including post-traumatic stress, depression and alcoholism.
It is, therefore, urgent to deal with mental problems.
There are groups at special risk of developing mental problems
•
Beyond the striking statistics related to suffering from defined mental
disorders, there are many categories of people who, because of extremely
difficult circumstances, are at special risk of being affected by mental
problems. Amongst them are persons living in extreme poverty, such as slum
dwellers; children and adolescents experiencing disrupted nurturing, abused
women, abandoned elderly people, others traumatised by violence, such as
the victims of armed conflicts, migrants, including refugees, and many
indigenous persons.
Mental health and well-being now constitute important challenges for mankind
Since physical illness and disease, wars, violence and poverty in the world are
unlikely to disappear, and biological predispositions to mental problems will continue
to affect a great many people. Mental problems need to be addressed now and in
the future.
Mental health problems will only be addressed when there is sufficient
awareness, commitment and resource allocation
Mental health and well-being have nearly always had a lower priority than
communicable diseases and other 'physical' maladies, despite their significant
impact on mortality and morbidity. But we are now in a position to make use of the
wealth of knowledge and technology that allows us to effectively manage, treat and
prevent a wide range of mental health, neurological and substance use problems.
•
It is time to review priorities and commitments and to recognize that
substantial benefits will accrue through investing in mental health. Many
communicable diseases are now under control, but only as a result of public
awareness and a commitment to address the problem.
4
Key mental health issues for all countries of Europe
•
What is the level of responsibility of the public sector in addressing mental
health issues and maintaining the highest possible standards for mental
health in the midst of economic recession and an associated decline in
resources?
•
How do we find the appropriate balance between mental health promotion,
which seeks to improve the mental health and well being of entire
populations, and mental health service delivery, whose aim is to improve the
mental health and living conditions of individuals suffering from mental
problems and of their families?
For further information, journalists can contact:
WHO Press Spokesperson and Coordinator, Spokesperson's Office,
WHO HQ, Geneva, Switzerland / Tel +41 22 791 4458/2599 / Fax +41 22 791 4858 / e-Mail:
inf@who.int
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Fact Sheets
Fact Sheet N° 218
April 1999
THE ’UNDEFINED AND HIDDEN’ BURDEN
OF MENTAL HEALTH PROBLEMS
The Undefined Burden of mental problems refers to the economic and social
burden for families, communities and countries. Although obviously substantial, this
burden has not been efficiently measured. This is because of the lack of quantitative
data and difficulties in measuring and evaluating.
The Hidden Burden refers to the burden associated with stigma and violations of
human rights and freedoms. Again, this burden is difficult to quantify. This is a major
problem throughout the world, as many cases remain concealed and unreported.
Undefined Burden
Mental illnesses affect the functioning and thinking processes of the individual,
greatly diminishing his or her social role and productivity in the community. In
addition, because mental illnesses are disabling and last for many years, they take a
tremendous toll on the emotional and socio-economic capabilities of relatives who
care for the patient, especially when the health system is unable to offer treatment
and support at an early stage. Some of the specific economic and social costs
include:
o
lost production from premature deaths caused by suicide (generally
equivalent to, and in some countries greater, than deaths from road traffic
accidents);
•
lost production from people with mental illness who are unable to work, in the
short, medium or long term;
•
lost productivity from family members caring for the mentally-ill person;
•
reduced productivity from people being ill while at work;
•
cost of accidents by people who are psychologically disturbed, especially
dangerous in people like train drivers, airline pilots, factory workers;
»
supporting dependents of the mentally ill person;
•
direct and indirect financial costs for families caring for the mentally-ill person;
•
unemployment, alienation, and crime in young people whose childhood
problems, e.g., depression, behaviour disorder, were not sufficiently well
addressed for them to benefit fully from the education available;
•
poor cognitive development in the children of mentally ill parents, and the
•
emotional burden and diminished quality of life for family members.
2
The Hidden Burden
Stigma can be defined as a mark of shame, disgrace or disapproval which results in
an individual being shunned or rejected by others. The stigma associated with all
forms of mental illness is strong but generally increases the more an individual's
behaviour differs from that of the 'norm'.
Because of stigma, persons suffering from a mental illness are:
•
often rejected by friends, relatives, neighbours and employers leading to
aggravated feelings of rejection, loneliness and depression;
•
often denied equal participation in family life, normal social networks, and
productive employment;
Stigma has a detrimental effect on a mentally ill person's recovery, ability to
find access to services, the type of treatment and level of support received
and acceptance in the community;
•
•
Rejection of people with mental illness also affects the family and caretakers
of the mentally ill person and leads to isolation and humiliation; and
»
A major cause of stigma associated with mental illness are the myths,
misconceptions and negative stereotypes about mental illness held by many
people in the community.
The stigma can be reduced by:
•
openly talking about mental illness in the community;
•
providing accurate information on the causes, prevalence, course and effects
of mental illness;
•
countering the negative stereotypes and misconceptions surrounding mental
illness;
•
providing support and treatment services that enable persons suffering from a
mental illness to participate fully in all aspects of community life;
•
ensuring the existence of legislation to reduce discrimination
workplace, in access to health and social community services.
in
the
Human rights violations
Persons experiencing mental problems are more vulnerable than others in their
social dealings and, as a result, are at a relatively higher risk to have their human
rights and freedoms violated. These include:
•
the right not to be discriminated against (e.g., in access to health care, social
services or employment);
.
the right to liberty (e.g., not to have restrictions automatically imposed on
freedom of movement through measures such as detention);
•
the right to integrity of the person (e.g., not to be unduly subjected to mental
or physical harm. Typical violations include treatment that ignores the
requirement to obtain either the patient's informed consent or a surrogate
decision-maker's, and sexual abuse);
•
The right to control one's own resources (e.g., one should not be
automatically removed on the mere grounds of status as a mental patient, but
should be judged on his or her actual ability to manage resources).
3
Mental health legislation — a necessary requirement
General principles for mental health legislation to protect the rights of the mentally ill
include:
•
Respect for individuals and their social, cultural, ethnic, religious
and philosophical values.
•
Individuals' needs taken fully into account. Individual's need for health
and social care must be assessed thoroughly. In particular, it is important
to ensure that the views of an individual (and his or her carers) are
considered. For this to happen, there must be close liaison between
health, housing and social care services.
•
Care and treatment provided in the least restrictive environment. In
order to uphold this principle, legislation should be framed so that
involuntary (formal) hospital admission is a last resort. This can be
achieved through: clearly defined grounds for detention; procedural
safeguards when the power to detain is used; an obligation to discharge
when grounds for detention are no longer met; an independent review of
the decision to detain.
»
Provision of care and treatment aimed at promoting each individual's
self- determination and personal responsibility. It is vital that
individuals are given the opportunity to exercise choice and make
decisions about their own care and treatment. Legislation should aim to
ensure that: treatment can be imposed only in strictly limited and clearly
defined circumstances and must be the least restrictive alternative; where
individuals are unable to make decisions for themselves, steps are taken
to find out their wishes and feelings; clear information on treatment and
detention is readily available; appropriate provisions for confidentiality are
in force.
o
Provision of care and treatment aimed at achieving the individual's
own highest attainable level of health and well-being. In addition, to
issues of quality and continuity of care, this principle addresses the
question of a "right" to treatment. It can also cover more general issues
such as the requirement that the individual should be cared for properly in
a safe environment and subject only to restrictions for reasons of his or
her health or safety, or the safety of others. In this regard: there should be
no restrictions on an individual's contact with friends and family, except in
rare and clearly defined circumstances; stringent safeguards from abuse,
exploitation and neglect should be in place.
For further information, journalists can contact:
WHO Press Spokesperson and Coordinator, Spokesperson's Office,
WHO HQ, Geneva, Switzerland / Tel +41 22 791 4458/25991 Fax +41 22 791 4858 / e-Mail:
inf@who.int
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Fact Sheet N° 219
April 1999
STRENGTHENING COMMUNITY MENTAL HEALTH
SERVICES AND PRIMARY CARE
Community mental health services and primary care
During the past 20 years there have been radical changes in psychiatric care in
Europe as a result of "deinstitutionalisation" of psychiatric patients. That is to say,
those previously kept in large public mental hospitals were now discharged and
reintegrated into the community where they received treatment and care. It had
become clear that these institutions caused long-term damage to individuals' health
and ability to function in society.
Deinstitutionalisation means (1) avoiding mental hospital admissions through the
provision of community treatment alternatives, (2) the release into the community of
all institutionalised patients who have been given adequate preparation for such a
change, and (3) the establishment and maintenance of community support systems
for non-institutionalised people.
Whilst the deinstitutionalisation process is much more advanced in Western Europe
than in Eastern Europe, the issue of strengthening community mental health
services is relevant for all European countries.
There is broad scientific support for the belief that an approach to treatment and
care based on deinstitutionalisation and its replacement by community treatment
and care leads to better results in respect to (1) global symptoms of mental illness,
(2) psycho-social adjustment, (3) admission and readmission rates to mental
hospitals, (4) length of hospital stay, (5) employment and (6) reduced burden for the
family.
Clinical trials have shown that the important elements of an effective response to
mental health and neurological problems are psychological and social intervention
(independent living skills, training in social skills, vocational training, social support
networks, family intervention) and pharmacotherapy (neuroleptics, lithium,
antidepressants and anxiolytics).
For most disorders it is essential that pharmacotherapy be used in combination with
other specific psychological and social interventions.
The efficacy of these treatments will be reduced substantially if they are not
delivered within the context of a comprehensive and coordinated delivery service.
Requirements of a comprehensive community mental health service include:
•
crisis intervention
•
beds for acute episodes of severe and acute illness in general hospitals
•
long-stay accommodation with a 24-hour staff in home-like units, for people
2
with enduring mental illness who need regular supervision of medication and
daily monitoring of their mental state but who do not require the continuous
presence of medical staff
•
day care programmes
•
concerted outreach efforts
•
supported housing
o
home services
•
occupational rehabilitation programmes
°
patient and family support services
•
multidisciplinary health care teams.
Requirements of primary health care are (1) an adequately trained staff to
assess, diagnose and manage mental problems, (2) availability of essential drugs
for the treatment of mental disorders, (3) establishment of effective links with more
specialist care, including well developed criteria for referral, methods of shared care,
adequate information systems and communication, and (4) creation of appropriate
links with other community and social services.
WHO is supporting the creation of a number of demonstration projects in 14
countries to strengthen community mental health services and primary health care.
The major themes include (1) increasing the awareness of the community and
educating it about mental health, (2) deinstitutionalisation, (3) reorganisation of
mental health services, (4) creation of community mental health services and
outreach programs, (5) training of primary care providers, (6) training of
psychiatrists, and (7) psycho-social rehabilitation.
For further information, journalists can contact:
WHO Press Spokesperson and Coordinator, Spokesperson's Office,
WHO HQ, Geneva, Switzerland / Tel +41 22 791 4458/2599 / Fax +41 22 791 4858 / e-Mail:
inf@who.int
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Fact Sheet N° 220
April 1999
STRENGTHENING MENTAL
HEALTH PROMOTION
Mental health is not just the
absence of mental disorder
•
The positive dimension of mental health is stressed in WHO's definition of
health as contained in its constitution: "Health is a state of complete physical,
mental and social well-being and not merely the absence of disease or
infirmity." WHO's 191 member states have endorsed this sweeping
statement.
How does one define mental health?
o
It is a state of well-being in which the individual realises his or her own
abilities, can cope with the normal stresses of life, can work productively and
fruitfully, and is able to make a contribution to his or her community.
•
Mental health promotion is an umbrella term that covers a variety of
strategies, all aimed at having a positive effect on mental health. The
encouragement of individual resources and skills and improvements in the
socio-economic environment are among them.
o
Most health care resources are spent on the specialised treatment and care
of the mentally ill, and to a lesser extent on community treatment and
rehabilitation services. Even less funding is available for promoting mental
health.
•
Mental health promotion requires multi-sectoral action, involving a number of
government sectors such as health, employment/industry, education,
environment, transport and social and community services as well as non
governmental or community-based organisations such as health support
groups, churches, clubs and other bodies.
Enhancing the value and visibility of mental health
•
National mental health policies should not be solely concerned with mental
illness but recognise and address the broader issues affecting the mental
health of all sectors of society. These would include the social integration of
severely marginalized groups, such as refugees, disaster victims, the socially
alienated, the mentally disabled, the very old and infirm, abused children and
women, and the poor.
Mental health promotion for children and adolescents
•
Psychosocial and cognitive development of babies and infants depends upon
their interaction with their parents. Programmes that enhance the quality of
these relations can improve substantially the emotional, social, cognitive and
2
physical development of children. These activities are particularly meaningful
for mothers living in conditions of stress and social adversity. WHO has
developed an international programme to stimulate mother-infant interaction
that has been widely adopted.
•
It is clear that schools remain a crucial social institution for the education of
children in preparation for life. But they need to be more involved in a broader
educational role fostering healthy social and emotional development of pupils.
•
WHO has developed a 'life skills' educational curriculum, which teaches a
wide range of skills to school age children to improve their psychosocial
competency.
The
skills
include
problem-solving,
critical
thinking,
communication, interpersonal skills, empathy, and methods to cope with
emotions. These skills enable children and adolescents to develop sound and
•
"Child-friendly schools" are another WHO mental health initiative to promote
a sound psychosocial environment in the school to complement the life skills
curriculum. A child-friendly school encourages tolerance and equality
between boys and girls and different ethnic, religious and social groups. It
promotes active involvement and cooperation, avoids the use of physical
punishment, and does not tolerate bullying. It is also a supportive and
nurturing environment; providing education which responds to the reality of
the children's lives. Finally, it helps to establish connections between school
and family life, encourages creativity as well as academic abilities, and
promotes the self-esteem and self-confidence of children.
positive mental health.
Working life and employment
•
Special emphasis should be given to those aspects of work places and the
work process itself which promote mental health. Eight areas of action have
been identified: increasing an employer's awareness of mental health issues;
identifying common goals and positive aspects of the work process; creating
a balance between job demands and occupational skills; training in social
skills; developing the psycho-social climate of the workplace; provision of
counselling; enhancement of working capacity, and early rehabilitation
strategies.
•
Another
significant
issue
is
unemployment,
in
particular,
youth
unemployment. In this area, mental health promotion strategies seek to
improve employment opportunities, for example, through programmes to
create jobs, provide vocational training, and social and job seeking skills.
Mental health promotion and the ageing population
•
Ageing of the population is a highly desirable and natural aim of any society.
By 2025 there will be 1.2 billion older people in the world, close to threequarters of them in the developing world. But if ageing is to be a positive
experience it must be accompanied by improvements in the quality of life of
those who have reached - or are reaching - old age.
•
WHO is responding to the challenge by launching a "global movement on
active ageing". This is a new network for all those interested in policies and
practices concerning active, ageing. In this respect active ageing
encompasses all dimensions, physical, mental and social. WHO considers
that only by promoting older persons' citizen rights and aspirations will they
3
be able to live their lives to their full potential. A healthy, active older person is
a resource for the family, the community and the economy. The "global
movement on active ageing" takes in all of civil society and will be
symbolically launched on 2 October 1999, the International Day of Older
Persons, as part of the International Year of the same name.
Measuring and promoting quality of life
®
WHO has developed a tool to assess quality of life as an additional
measurement, along with the traditional morbidity and mortality data. A
primary goal of mental health promotion is to help member states improve the
quality of life of their people and to place mental health firmly on the national
agenda.
For further information, journalists can contact:
WHO Press Spokesperson and Coordinator, Spokesperson's Office,
WHO HQ, Geneva, Switzerland / Tel +41 22 791 4458/25991 Fax +41 22 791 4858 / e-Mail:
inf@who.int
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Fact Sheet No 248
June 2000
WOMEN AND MENTAL HEALTH
Background
In many under-served populations, women have considerable mental health needs.
However, until recent years, the conception of women's mental health has been
limited as have attempts to protect and promote it. When women's health issues
have been addressed in these populations, activities have tended to focus on issues
associated with reproduction - such as family planning and child-bearing - while
women's mental health has been relatively neglected (WHO, 1993; WHO, 1995).
Women are integral to all aspects of society. However, the multiple roles that they
fulfill in society render them at greater risk of experiencing mental problems than
others in the community. Women bear the burden of responsibility associated with
being wives, mothers and carers of others. Increasingly, women are becoming an
essential part of the labour force and in one-quarter to one-third of households they
are the prime source of income (WHO, 1995).
In addition to the many pressures placed on women, they must contend with
significant gender discrimination and the associated factors of poverty, hunger,
malnutrition and overwork. An extreme but common expression of gender inequality
is sexual and domestic violence perpetrated against women. These forms of socio
cultural violence contribute to the high prevalence of mental problems experienced
by women.
Significant mental disorders and problems experienced by women
In investigating common mental, behavioural and social problems in the community
we find that women are more likely than men to be adversely affected by specific
mental disorders, the most common being: anxiety related disorders and
depression; the effects of domestic violence; the effects of sexual violence; and
escalating rates of substance use.
Mental disorders
Prevalence rates of depression and anxiety disorders as well as psychological
distress are higher for women than for men. These findings are consistent across a
range of studies undertaken in different countries and settings (Desjarlais et al,
1995). In addition to the higher rates of depression and anxiety, women are much
more likely to receive a diagnosis of obsessive compulsive disorder, somatization
disorder and panic disorder (Russo, 1990). In contrast men are more likely to
receive
a
diagnosis
of
antisocial
personality
disorder
and
alcohol
abuse/dependency. The gender differences associated with mental disorders are
brought out most clearly in the case of depression (Russo, 1990). Data from the
2
World Bank study revealed that depressive disorders accounted for close to 30% of
the disability from neuropsychiatric disorders amongst women in developing
countries but only 12.6% of that among men. The disparity in rates between men
and women tend to be even more pronounced in underserved populations (World
Bank, 1993).
Gender differences in mental disorders
Explanations for the gender differences in mental disorders have been discussed in
relation to different help-seeking behaviours of the sexes, biological differences,
social causes and the different ways in which women and men acknowledge and
deal with distress (Paykel, 1991). Blue et al, (1995) argue that while all these factors
may contribute to higher rates of depression or psychological problems among
women, social causes seem to be the most significant explanation. Women living in
poor social and environmental circumstances with associated low education, low
income and difficult family and marital relationships, are much more likely than other
women to suffer from mental disorders. They conclude that the combined impact of
gender and low socio-economic status are critical determinants of mental ill-health
(Blue etal, 1995).
Promoting women's mental health
It is essential to recognise how the socio-cultural, economic, legal, infrastructural
and environmental factors that affect women’s mental health are configured in each
country or community setting. A gender-based, social model of health needs to be
adopted to investigate critical determinants of women’s mental health with the
overall objective of contributing to improved, more effective promotion of women’s
mental health. Risk factors for mental disorder as well as for good mental health
need to be addressed and where possible, a clear distinction should be made
between the opportunities that exist for individual action and individual behaviour
change and those that are dependent on factors outside the control of the individual
woman.
To help clarify the meaning women themselves ascribe to mental health and various
forms of psychological distress, findings from qualitative research need to augment
those from quantitative research. Descriptions of life situations, case studies and
direct quotes from women themselves can vivify the contexts in which emotional
distress, depression, anxiety and other psychological disorders occur. Such first
hand accounts of the experiences of poverty, inequality and violence will assist in
developing a more accurate understanding of the structural barriers women face in
attempting to exercise control over the determinants of their mental health and in
effecting behavioural change. Both are needed to better inform the promotion of
women’s mental health.
Women’s views and the meanings they attach to their experiences have to be
heeded by researchers, health care providers and policy makers. Without them,
research and the evidence it gathers, service delivery and policy formation, will be
hampered in responding to women's identified health priorities, problems and needs.
Moreover, all three will be ignorant of the nature and magnitude of unmet needs and
unaware of the factors influencing women’s utilisation of health care.
The identification and modification of the social factors that influence women’s
3
mental health holds out the possibility of primary prevention of certain mental
disorders.
Further Reading
1. Women’s mental health: An evidence based review, WHO, March 2000.
For further information, journalists can contact:
WHO Press Spokesperson and Coordinator, Spokesperson's Office.
WHO HQ, Geneva, Switzerland / Tel +41 22 791 4458/2599 / Fax +41 22 791 4858 / e-Mail:
inf@who.int
Stop Exclusion
Dare to Care
WORLD
HEALTH
DAY
7
APRIL
200 1
Message from the
Regional Director
opulations of Member Countries of the World Health Organization's South-East
Asia Region have suffered for ages from many communicable diseases. While
some of these have been successfully controlled, others continue as serious
public health problems. However, recently, it has become increasingly clear that
noncommunicable diseases, including mental and neurological disorders, are important
causes of suffering and death in the Region. An estimated 400 million people world-wide
suffer from mental and neurological disorders or from psychosocial problems such
as those related to alcohol and drug abuse. Our Region accounts for a substantial
proportion of such people. Thus, the Region faces the double burden of diseases - both
communicable and noncommunicable. Moreover, with the population increasing in
number and age, Member Countries will be burdened with an ever-growing number of
patients with mental and neurological disorders.
As Dr Gro Harlem Brundtland, the Director-General of the World Health Organization
says, “Many of them suffer silently, and beyond the suffering and beyond the absence
of care lie the frontiers of stigma, shame, exclusion and, more often than we care to
know, death”.
While stigma and discrimination continue to be the biggest obstacles facing mentally ill
people today, inexpensive drugs are not reaching many people with mental and
neurological illnesses. Although successful methods of involving the family and the
community to help in recovery and reduce suffering and accompanying disabilities have
been identified, these are yet to be used extensively. Thus, many population groups still
remain deprived of the benefits of advancement in medical sciences. Dr Brundtland has
said, "By accident or design, we are all responsible for this situation today."
The World Health Organization recently developed a new global policy and strategy for
work in the area of mental health. Launched by the Director-General in Beijing in
November 1999, the policy emphasises three priority areas of work: (1) Advocacy to
raise the profile of mental health and fight discrimination; (2) Policy to integrate mental
health into the general health sector, and (3) Effective interventions for treatment and
prevention and their dissemination. The South-East Asia Regional office of the World
Health Organization is committed to promoting this policy.
Mental health care, unlike many other areas of health, does not generally
demand costly technology. Rather, it requires the sensitive deployment of
personnel who have been properly trained in the use of relatively inexpensive
drugs and psychological support skills on an outpatient basis. What is needed, above
all, is for all concerned to work closely together to address the multi-faceted challenges
of mental health.
UfUton Muchtar Rafei
Regional Director, WHO South-East Asia Region
WORLD
HEALTH
DAY
7
APRIL
200 1
Agenda for the
Mental Health Programme
in the South-East Asia Region
ental health can be measured in terms of a person’s well-being where
he/she is able to maintain “an inner sense of comfort” in as many life
. situations as possible. Mental health can also be seen in terms of how good
individuals feel about themselves, feel comfortable with other people and cope with
the demands and stresses of everyday life.
Historically, disease burden has been based on mortality statistics, which do not
take into account non-fatal conditions such as neuropsychiatric illnesses. When
disease burden measurements include an element of the time lived with disability,
neuropsychiatric conditions emerge as major contributors to the suffering of
populations. According to the World Health Report 1999, an estimated 10% of the
burden from noncommunicable diseases measured in disability-adjusted life years in
1998 was accounted for by neuropsychiatric conditions in low and middle income
countries. Neuropsychiatric conditions were responsible for the loss of one out of ten
disability-adjusted life years in these countries. Population-based data on the
magnitude of these conditions in Member Countries of the WHO South East Asia
Region (SEAR) are now being compiled.
in SEAR Member Countries, mental health programmes have generally concentrated
on hospital-based psychiatry. However, there is increasing awareness in these
countries of the need to shift the emphasis to community-based mental health
programmes. The WHO Regional Office for South-East Asia is concentrating on
supporting Member Countries on the development of community-based mental
health programmes and also programmes for prevention of harm from alcohol and
substances of abuse. The programmes will be culturally and gender appropriate and
reach out to all segments of the population, including marginalized groups.
There are many barriers to the implementation of community mental health
projects and programmes. While some countries have developed mental health
policies, there has not been adequate implementation. Governments urgently need
to be sensitized on the importance of mental health and to clearly define the goals
and objectives for community-based mental health programmes. Mental health
services should be integrated into the overall primary health care system. At the
same time, innovative community-based programmes need to be developed and
research into relevant issues and traditional practices promoted. Communities have
to be educated and informed about mental and neurological illnesses to remove the
numerous myths and misconceptions about these conditions. But most important,
the stigma and the discrimination associated with mental illness must be removed.
The Regional Office is developing strategies for community-based programmes based
on five ‘A’s: Availability, Acceptability, Accessibility, Affordable medications and
Assessment.
Availability: Services which will address at least the minimum needs of populations
in mental and neurological disorders should be available to everyone regardless of
where they live. The key questions are: what are the minimum services needed and
who will deliver them?
Acceptability: Large segments of populations in the countries continue to perpetuate
superstitions and false beliefs about mental and neurological illnesses. Many believe
that these illnesses are due to “evil spirits”. Thus, even if appropriate medical services
are made available, they would rather go to sorcerers and faith healers. Populations
need to be informed and educated about the nature of neuropsychiatric illnesses.
Accessibility: Services should be available to the community, in the community, and
at convenient times. If a worker has to give up his daily wages, and travel a
substantial distance to see a medical professional who is only available for a few
hours a day, he/she is unlikely to seek these services.
Affordable medications: Frequently, medications are beyond the reach of the poor.
Every effort should be made to provide essential medications uninterruptedly and at
a reasonable cost. Thus, government policies in terms of pricing and the role of the
pharmaceutical industry in distribution and pricing become critical.
Assessment: Being new, these programmes need to be continuously assessed to
ensure appropriateness and cost-effectiveness. Changes in the ongoing programmes
based on impartial evaluations are essential.
Lucretius, the great Roman philosopher and poet who lived from 96 BC to 55 BC
wrote:.“The mind, like a sick body, can be healed and changed by medicine." Two
thousand years later, we must accept and implement what Lucretius said. To this,
we must add social and psychological support which should be extended to those
suffering from mental and neurological illnesses to ensure that they get optimum
treatment, care, love and affection to enjoy life with dignity.
Dr Vijay Chandra
Regional Adviser, Health & Behaviour,
WHO/SEARO, New Delhi
World Health Day, 7 April 2001
Dedicated to Mental Health
World Health Organization
Regional Office for South-East Asia
Mental Health in South-East Asia:
Reaching
OUt
community
WHO defines health as, “A state of complete physical, mental and social wellbeing
and not merely the absence of disease or infirmity”. Thus mental health should be
an integral part of all health programmes. Mental illness includes mental disorders,
neurological and psychosocial problems such as those related to alcohol and drug
abuse.
What are mental disorders?
Mental disorders are characterized by psychological and behavioural
symptoms, resulting from changes in one’s thinking, attention, concentration,
memory and judgement. Changes in these mental functions, lasting for a prolonged
duration cause abnormalities in speech and behaviour that may differ from socially
and culturally accepted norms. Such changes in mental functions can also cause
varying degrees of distress to the individuals, their families, and at times, the
community. Psychological and behavioural symptoms may also result in
impairments in personal, social and occupational functioning.
It is important to view behavioural changes in the context of the prevailing
social and cultural milieu. What is considered normal in one culture may be
unacceptable in another setting.
There are various types of mental and neurological disorders and psychosocial
problems such as psychotic disorders (e.g. schizophrenia), mood disorders (e.g.
depressive disorders), neurotic, stress-related and adjustment disorders (e.g.
obsessive compulsive disorder, anxiety disorder), neurological disorders (e.g.
Alzheimer's disease, epilepsy and mental retardation); childhood mental disorders
(e.g. attention deficit hyperactivity disorder), and substance abuse-related
disorders (e.g. alcoholism, drug abuse).
What causes mental disorders?
A complex interaction process between various genetic, biological, psychological
and sociocultural factors causes mental disorders. Links have been established
between the occurrence of certain types of mental disorders and adverse social
conditions such as poverty, high rates of unemployment, homelessness, illiteracy, and
gender discrimination. Severe malnutrition can result in cognitive impairment, impaired
childhood development, stress and demoralization.
There are several groups of people who have a higher risk for developing mental
disorders. These include people, socially isolated, abandoned elderly people,
abused women, people belonging to ethnic minority groups, children and
adolescents experiencing disturbed nurturing. Others are displaced persons, migrants,
refugees, adults from broken families, people with other family members affected by
psychiatric illness and people who are traumatized by violence, and populations
affected by disasters. While these are some possible risk factors for neuropsychiatric
illnesses in general, there may be specific risk factors for individual diseases.
Public health significance of mental disorders
Mental disorders are known to be widely prevalent Today, about 400 million
people are estimated to be suffering globally from various types of mental and
neurological disorders including disorders caused by alcohol and drug abuse. One
out of every four persons seeking primary care service suffers from such disorders.
About one million suicides are reported every year. A majority of those committing
suicide are known to have suffered from depressive disorder. Using Disability
Adjusted Life Years (the DALY, expresses years of life lost to premature death and
years lived with a disability of specified severity and duration. One DALY is thus one
lost year of healthy life) as a basis for measurement, mental disorders have been
found to be amongst the significant contributors to the Global Burden of Disease
(GBD). According to the World Health Report 1999, an estimated 10% of the burden
from noncommunicable diseases in 1998 was accounted for by neuropsychiatric
conditions in low and middle-income countries. Five of the ten leading causes of
disability worldwide are already mental disorders (unipolar depression,
schizophrenia, bipolar affective disorders or manic depressive disorder, alcoholism
and obsessive-compulsive disorder.). This situation will soon apply to developing
countries including SEAR Member Countries.
Estimates of the prevalence of major mental and neurological
disorders in the South-East Asia Region are as follows:
Schizophrenia: It affects about seven adults per thousand in the population,
mostly in the age group 15-35 years. Dr R.D. Laing, a British psychiatrist wrote:
“Schizophrenia cannot be understood without understanding despair." This was
written in the early twentieth century, but still remains true for a majority of
sufferers despite the availability of effective medications.
2
In SEAR: Developing countries have been consistently shown to have a lower
number and better outcome of cases of schizophrenia than developed countries.
One of the reasons for this could be the availability of better social support systems
in these countries.
Depression: Establishing a diagnosis of depression versus a normal fluctuation in
mood is a crucial issue in estimating the true prevalence of depression in the
community. It is estimated that 5-10% of the population in the community at any
given time suffers from identifiable depression needing psychiatric or psychosocial
intervention. The lifetime risk of developing depression is 15-17 per 100 in females
and slightly less in males.
In SEAR: In the last fifty years, treatment of depression has made rapid strides.
Newer drugs are being discovered with better efficacy, less side-effects and better
tolerance, and are being used for short-term and long-term treatment. Besides
drugs, nonpharmacological therapies like psychotherapy and cognitive therapy have
been found beneficial. Unfortunately, despite the seriousness of depression and all
the associated consequences which can be effectively treated at any level of care,
only 30% of cases all over the world with these disorders are properly diagnosed or
treated. The situation about the lack of adequate diagnostic and treatment
services may be worse in SEAR Member Countries.
Anxiety disorders: Anxiety is a common experience in daily life and must be
differentiated from anxiety disorder which causes substantial suffering in the
general population. Generalized anxiety disorder, panic disorder, phobia and
obsessional disorder are also now considered in the group of anxiety disorders.
Considering all the anxiety disorders together, data from western countries report
the prevalence estimates as high as 10 to 15% of the population.
In SEAR: Although there are no definitive data on the prevalence of anxiety
disorders in SEAR, indirect evidence suggest, that the prevalence of these conditions
is as high as in western countries and perhaps increasing due to the changing social
and cultural environment Moreover, the easy availability of tranquilizers used
widely by the common man as a remedy for anxiety, is a cause of concern.
Suicide: Suicide rates vary from 8-50 per 100 000 population in countries of the
South-East Asia Region. India and Sri Lanka record the highest number of suicide
rates (11 and 37 per 100 000 population respectively) and occupy the 45th and 7th
positions globally. Nearly 2 548 persons in Bangladesh, 4 840 in the Democratic
People's Republic of Korea, 104 000 persons in India, 5 616 in Sri Lanka and 5 095 in
Thailand committed suicide during 1997-98 as per official reports.
In SEAR: SEAR Member Countries are witnessing rapid changes in population
growth, socioeconomic development and health profiles. Suicide is now being
recognized as a major public health problem in the complex scenario of
development and lifestyle changes, in the socioculturally diverse communities of
SEAR, suicide is a very important issue cutting across diverse disciplines and sectors
such as health, religion, spirituality, law and welfare.
3
Epilepsy: Epilepsy affects 2-10 per 1000 population. Studies from different parts
of India reveal that the problem varies from 9 per 1000 in Bangalore, 5 per 1000 in
Mumbai, 4 per 1000 in New Delhi and 3 per 1000 in Calcutta area. In a survey
conducted in the Kandy district of Sri Lanka, it was observed that 9 out of 1000
people had epilepsy. Though there are no national statistics from Bangladesh, it is
estimated that there are at least 1.5-2.0 million people with epilepsy.
In SEAR: The World Health Organization, in partnership with the International
League against Epilepsy, and the international Bureau for Epilepsy, has launched a
worldwide public awareness programme, “Out of the Shadows". The programme,
also being implemented in some SEAR countries, should help to create awareness,
remove myths and misconceptions and make available appropriate care and
treatment to people with epilepsy.
Mental retardation: Generally, mental retardation affects 2% of the population
of all ages. Mild mental retardation is much more common, accounting for 65 to 75%
of all cases of mental retardation. Looked at another way, in a population of 1 000
people, of the 20 who will have mental retardation, about 15 will have mild mental
retardation and about five will have more severe forms of mental retardation.
in SEAR: Mental retardation is a common problem in SEAR Member Countries,
affecting not only the individuals who have this problem but also their families and
society as a whole. Several positive advances in the scientific and social
understanding of this problem have opened up a variety of avenues and
opportunities to reduce this problem and limit the extent of disability. One such
successful programme is the control of mental retardation due to iodine deficiency
which has largely been brought under control by iodination of salt. Combined and
coordinated action by the families, governments and nongovernmental
organizations is urgently needed.
Alzheimer's disease: It is estimated that there are currently about 18 million
people worldwide with Alzheimer’s disease. This figure is projected to nearly
double by 2025 to 34 million. Much of this increase will be in developing countries,
and will be due to the aging population. Currently, more than 50% of people with
Alzheimer’s disease live in developing countries and by 2025, there will be over 70%
of such people.
Studies on Alzheimer’s disease in South India, Mumbai and the northern state
of Haryana in India have reported very low rates of occurrence of Alzheimer’s
disease in those 65 years or older, ranging from about 1% in rural north-lndia (the
lowest reported from anywhere in the world where Alzheimer’s disease has been
studied systematically) to 2.7% in urban Chennai. Studies from China and Taiwan
have also shown a lower risk of Alzheimer’s disease in these countries as compared
to western countries. Thus, from existing evidence, it would appear that the
number of cases of Alzheimer’s disease in Asia, and particularly in India and Africa,
is lower than those reported from studies in developed countries. The reasons for
these differences are a topic of intense research.
Epilepsy Epilepsy affects 2-10 per 1000 population. Studies from different parts
of India reveal that the problem varies from 9 per 1000 in Bangalore, 5 per woo in
Mumbai 4 per WOO in New Delhi and 3 per WOO in Calcutta area. In a survey
conducted in the Kandy district of Sri Lanka, it was observed that 9 out of WOO
people had epilepsy. Though there are no national statistics from Bangladesh, it is
estimated that there are at least 1.5-2.0 million people with epilepsy.
In SEAR: The World Health organization, in partnership with the International
League against Epilepsy, and the international Bureau for Epilepsy, has launched a
worldwide public awareness programme, "Out of the Shadows". The programme,
also being implemented in some SEAR countries, should help to create awareness,
remove myths and misconceptions and make available appropriate care and
treatment to people with epilepsy.
Mental retardation: Generally, mental retardation affects 2% of the population
of all ages. Mild mental retardation is much more common, accounting for 65 to 75%
of all cases of mental retardation. Looked at another way, in a population of 1 000
people, of the 20 who will have mental retardation, about 15 will have mild mental
retardation and about five will have more severe forms of mental retardation.
In SEAR: Mental retardation is a common problem in SEAR Member Countries,
affecting not only the individuals who have this problem but also their families and
society as a whole. Several positive advances in the scientific and social
understanding of this problem have opened up a variety of avenues and
opportunities to reduce this problem and limit the extent of disability. One such
successful programme is the control of mental retardation due to iodine deficiency
which has largely been brought under control by iodination of salt. Combined and
coordinated action by the families, governments and nongovernmental
organizations is urgently needed.
Alzheimer’s disease: it is estimated that there are currently about 18 million
people worldwide with Alzheimer’s disease. This figure is projected to nearly
double by 2025 to 34 million. Much of this increase will be in developing countries,
and will be due to the aging population. Currently, more than 50% of people with
Alzheimer’s disease live in developing countries and by 2025, there will be over 70%
of such people.
Studies on Alzheimer’s disease in South India, Mumbai and the northern state
of Haryana in India have reported very low rates of occurrence of Alzheimer's
disease in those 65 years or older, ranging from about 1% in rural north-lndia (the
lowest reported from anywhere in the world where Alzheimer’s disease has been
studied systematically) to 2.7% in urban Chennai. Studies from China and Taiwan
have also shown a lower risk of Alzheimer’s disease in these countries as compared
to western countries. Thus, from existing evidence, it would appear that the
number of cases of Alzheimer’s disease in Asia, and particularly in India and Africa,
is lower than those reported from studies in developed countries. The reasons for
these differences are a topic of intense research.
4
in SEAR: With an aging population, conditions such as Alzheimer's disease will
be a cause for concern in the near future. If it can be verified that the risk of
Alzheimer s disease is indeed lower in the eastern part of the world and the
reasons for this protection of the population determined, the developing countries
could perpetuate these factors and the developed countries could adopt them.
Alcohol abuse: There is clear evidence that alcohol-related morbidity and
mortality is high in most countries of the Region. Impairment due to excess alcohol
use also adds to the other negative consequences such as accidents due to
drunken driving, domestic violence and reduced productivity. Methanol poisoning
due to adulterated alcoholic beverages too is a problem in the Region.
Alcohol abuse in poor and deprived communities is particularly deleterious as
scarce financial resources of the family are diverted to alcohol rather than to food,
health care and education. Another phenomenon which is commonly seen is “pay
day binge drinking". Some wage earners spend their entire month’s earnings on
alcohol. Frequently, vendors wait outside places of employment on pay day to
entice workers to buy alcohol as they leave their place of work.
In India, in the mid 1990s, the adult male per capita consumption was 5-6 litres
and the prevalence of alcohol dependence syndrome was estimated to be 3.2
million. The total alcohol production more than doubled to 800 million litres
between 1993 and 1996. Fifty percent of all home and farm accidents were
estimated to be related to alcohol regularly.
In Sri Lanka, the adult per capita alcohol consumption increased from 3.79 to
5.11 litres between 1990 to 1997. A survey in the mid-1990s revealed that 43% of
urban shanty dwellers and 60% of estate workers consumed alcohol.
A 1991 survey in Thailand revealed that 31.4% of those over 14 years of age
consumed alcohol (54% of males and 10% of females). Thailand showed an 11-fold
increase in beer production between 1970 and 1993.
In the Democratic People’s Republic of Korea, the per capita consumption is
reported to be 3 litres, in Myanmar, 10% of all admissions to the Yangon Psychiatry
Hospital in 1994-96 were due to alcohol dependence. Cirrhosis of the liver, possibly
related to excess alcohol consumption, has been reported as the third most
common cause of death in Bhutan.
Systematic research aimed at estimating and understanding the nature and
extent of public health problems related to alcohol use in the Region is required.
Meanwhile, there is a need to implement effective strategies for prevention of
harm from alcohol. These strategies, which are being developed and implemented
include strategies for early identification and services for alcohol abuse and
dependence, campaigns aimed at reducing specific problems like drunken driving
and industrial accidents, and increasing public awareness about the harmful effects
of alcohol abuse.
5
Other substance abuse : Since times immemorial, in most countries of the
South-East Asia Region drugs have traditionally been used, in addition to alcohol, for
ritual, religious, and recreational purposes. These drugs were mainly cannabis
products and opium. The apparent social acceptance of the use of such substances
stemmed largely from the fact that there was no abuse. Where there was, it was
severely ostracized. Society had very clearly drawn the line and there was no
question of condoning any abuse.
The South-East Asia Region is particularly affected by the problem of substance
dependence. The notorious “Golden Triangle” (Myanmar, Laos, Thailand) is part of
the Region. India has become a major transhipment point for hard drugs from
Pakistan to the West Injecting illicit drugs has been fuelling the AIDS epidemic in
many countries of South-East Asia Region. The sharing of contaminated equipment
to inject drugs has been a key factor in spreading HIV/AIDS and other infections
among drug users.
Unfortunately, what we are witnessing today, on a global scale, is a virtual
epidemic of drug dependence. A disturbing trend is that more and more young
people are being drawn to this devastating addiction.
Social impact of mental disorders
The stigma associated with mental disorders leads to various negative
consequences not only for the sick person but also for his family members. These
include rejection, denial of equal opportunities and participation in various aspects
of life, humiliation and isolation. Persons with mental disorders are at high risk of
human rights violations. Despite the significant public health impact of mental
disorders on morbidity, disability and mortality, policy-makers and health care
administrators worldwide accord low priority to the development of mental health
services. A large proportion of persons with mental disorders do not receive any
meaningful care and have to feel undue suffering and disability.
What is community mental health
Community mental health (CMH) refers primarily to treatment and intervention
programmes initiated and implemented outside institutions such as mental
hospitals. In a narrow sense, CMH deals with the care of mentally ill persons in the
community. However, over the years, CMH has broadened its concern to address all
mental health problems of the population. Not only does CMH deal with different
levels of mental morbidity in a population but it is also concerned with the
perceived psychological welfare and wellbeing of society. CMH attempts to use
methods and techniques of behavioural sciences and public health to prevent
mental disorders, promote mental health and improve the general quality of life.
CMH also includes service delivery strategies for identification, management as well
as rehabilitation of persons with various mental disorders. The practice of CMH
requires coordinated and multisectoral action involving a number of government
sectors as well as nongovernmental and community-based organizations.
6
Successful community-based programmes:
in Bangladesh
Many NGOs are actively working for the welfare of persons with mental
retardation in Bangladesh. One such organization is the Bangladesh Protibandhi
Foundation (BPF). Started in 1984 as a parent - professional partnership, BPF has
been playing a key role in the area of mental retardation. BPF has been able to
initiate and sustain a variety of activities and programmes, which include health
care and psychological services, other professional services such as physiotherapy
and speech therapy, early stimulation programmes, a special school, and sheltered
workshop.
In India
Under the aegis of the National Mental Health Programme, the District Mental
Health Programme was started in 1982 in Bellary district of Karnataka, India. A
series of activities beginning with training of primary health centre workers,
evaluation of trained workers, and training of trainers formed the foundation of the
Programme.
The essential components were:
(a) training of health functionaries-, (b) continuous and uninterrupted provision of
essential drugs-, (c) a simple recording and reporting system-,
(d) continuous support and supervision by technical experts, and (e) community
participation and establishment of district units.
This model is able to deliver mental health services at the district level and is
gradually being expanded by the Government of India.
In Nepal
Programmes of orientation and sensitization of traditional healers on mental
disorders and epilepsy have been successfully conducted. This is of significance as
large number of patients and their family members have great faith in traditional
healers.
In Sri Lanka
'Sahanaya', a community mental health centre was established in 1983 by the
National Council for Mental Health in Colombo. The organization provides a range of
community-based mental health services by professionals and volunteers. Initial
and follow up assessments are done in detail with special reference to psychiatric,
psychological, social and other needs before deciding on a plan of action. A range
of skills for daily living and personal care including shopping and cleaning, is offered
to those suffering from disabilities associated with schizophrenia. Social,
occupational, recreational and vocational activities including gardening, dancing,
art, music and envelope making are also conducted.
In Thailand
An intervention programme in Thailand enlisted the support of village-level
health workers in preventing suicide. These people were trained in detecting
individuals with depression and those at risk of suicides, using basic helping skills
7
acquired from community work. After six months, suicides in the area declined
significantly and this programme is being replicated in other areas in the country.
Thailand has developed the programme of "school counsellors" in public schools.
The programme will be strengthened in future. A school-based general mental
health programme is also being implemented. These programmes address the
increasing mental health problems encountered amongst adolescents.
Conclusion
The Regional Director of WHO’s South-East Asia Region, Dr Uton Muchtar Rafei,
has very appropriately summarized the need for mental health in the Region:
“Mental health care, unlike many other areas of
health, does not generally demand costly
technology. Rather, it requires the sensitive
development of personnel who have been properly
trained in the use of relatively inexpensive drugs
and psychological support skills on an outpatient
basis. What is needed, above all, is for all concerned
to work closely together to address the multi
faceted challenges of mental health".
Prepared by:
or Nimesh G. Desai
Professor and Head,
Department of Psychiatry,
and Medical Superintendent,
Institute of Human Behaviour
and Allied Sciences,
New Delhi, India
Dr Mohan Isaac
Professor of Psychiatry,
National Institute of Mental Health
& Neuro Sciences. Bangalore, India
8
World Health Organization
Regional Office for South-East Asia
World Health House, Indraprastha Estate
New Delhi- 110 002 INDIA
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Better Understanding Appropriate Care in
Mental Health
World Health Organization
Regional Office for South-East Asia
Stop Exclusion
Dare to Care
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RF_MH_3_B_SUDHA.pdf
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