Chapter 1: A public health approach to mental health
Mental health is as important as physical health to the overall well-being of individuals, societies and countries. Yet only a small minority of the 450 million people suffering from a mental or behavioural disorder are receiving treatment. Advances in neuroscience and behavioural medicine have shown that, like many physical illnesses, mental and behavioural disorders are the result of a complex interaction between biological, psychological and social factors. While there is still much to be learned, we already have the knowledge and power to reduce the burden of mental and behavioural disorders worldwide.
For all individuals, mental, physical and social health are vital strands of life that are closely interwoven and deeply interdependent. As understanding of this relationship grows, it becomes ever more apparent that mental health is crucial to the overall well-being of individuals, societies and countries.
Unfortunately, in most parts of the world, mental health and mental disorders are not regarded with anything like the same importance as physical health. Instead, they have been largely ignored or neglected. Partly as a result, the world is suffering from an increasing burden of mental disorders, and a widening "treatment gap". Today, some 450 million people suffer from a mental or behavioural disorder, yet only a small minority of them receive even the most basic treatment. In developing countries, most individuals with severe mental disorders are left to cope as best they can with their private burdens such as depression, dementia, schizophrenia, and substance dependence. Globally, many are victimized for their illness and become the targets of stigma and discrimination.
Further increases in the number of sufferers are likely in view of the ageing of the population, worsening social problems, and civil unrest. Already, mental disorders represent four of the 10 leading causes of disability worldwide. This growing burden amounts to a huge cost in terms of human misery, disability and economic loss.
Mental and behavioural disorders are estimated to account for 12% of the global burden of disease, yet the mental health budgets of the majority of countries constitute less than 1% of their total health expenditures. The relationship between disease burden and disease spending is clearly disproportionate. More than 40% of countries have no mental health policy and over 30% have no mental health programme. Over 90% of countries have no mental health policy that includes children and adolescents. Moreover, health plans frequently do not cover mental and behavioural disorders at the same level as other illnesses, creating significant economic difficulties for patients and their families. And so the suffering continues, and the difficulties grow.
This need not be so. The importance of mental health has been recognized by WHO since its origin, and is reflected by the definition of health in the WHO Constitution as "not merely the absence of disease or infirmity", but rather, "a state of complete physical, mental and social well-being". In recent years this definition has been given sharper focus by many huge advances in the biological and behavioural sciences. These in turn have broadened our understanding of mental functioning, and of the profound relationship between mental, physical and social health. From this new understanding emerges new hope.
Today we know that most illnesses, mental and physical, are influenced by a combination of biological, psychological, and social factors (see Figure 1.1). We know that mental and behavioural disorders have a basis in the brain. We know that they affect people of all ages in all countries, and that they cause suffering to families and communities as well as individuals. And we know that in most cases, they can be diagnosed and treated cost-effectively. From the sum of our understanding, people with mental or behavioural disorders today have new hope of living full and productive lives in their own communities.
Figure 1.1 Interaction of biological, psychological and social factors in the development
This report presents information concerning the current understanding of mental and behavioural disorders, their magnitude and burden, effective treatment strategies, and strategies for enhancing mental health through policy and service development.
The report makes it clear that governments are as responsible for the mental health as for the physical health of their citizens. One of the key messages to governments is that mental asylums, where they still exist, must be closed down and replaced with well-organized community-based care and psychiatric beds in general hospitals. The days of locking up people with mental or behavioural disorders in grim prison-like psychiatric institutions must end. The vast majority of people with mental disorders are not violent. Only a small proportion of mental and behavioural disorders are associated with an increased risk of violence, and comprehensive mental health services can decrease the likelihood of such violence.
As the ultimate stewards of any health system, governments must take the responsibility for ensuring that mental health policies are developed and implemented. This report recommends strategies that countries should pursue, including the integration of mental health treatment and services into the general health system, particularly into primary health care. This approach is being successfully applied in a number of countries. In many parts of the world, though, much more remains to be accomplished.
Chapter 1: A public health approach to mental health :
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