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No health without mental health
By Karl de Souza
himnk...@gmail.com
Every year, October 10 is celebrated globally as World Mental
Health by the World Federation for Mental Health, as a
unified effort to promote greater public awareness and
understanding of mental health and mental illness.
According to the World Health Organisation (WHO)
constitution: "Health is a state of complete physical, mental
and social well-being and not merely the absence of disease
or infirmity", and mental health is a state of well-being in
which every individual realizes his/her own potential, coping
with the normal stresses of life, work productively, and
making a contribution to her/his community.
Unfortunately, even today a large proportion of
people with mental disorders around the world fail
to receive appropriate help in spite of new
treatments for mental illnesses. They suffer in
silence because of the stigma attached to mental
illness leading to reluctance to ask for help.
Lack of mental health puts a heavy burden on the individual,
the family and society. There are many different types of
mental health conditions, which can lead to a disability,
including dementia, depression, and schizophrenia. Major
depression ranks fourth in terms of disability, and WHO
predicts that in 20 years time more people will be affected
by depression than any other health problem.
Out of the estimated 450 million people globally
who have a mental health disorder, fewer than half
receive the help they need. According to Shraddha
Rehabilitation Foundation in Maharashtra, mental
disorders afflict five crore of the Indian
population. Some 80% of our districts do not have
even one psychiatrist in public service.
In fact, there are just about 3,500-5,000 psychiatrists in
India or three psychiatrists per one million people. Inspite
of WHO estimates of 2001 indicate a prevalence level of about
22% of individuals developing one or more mental or
behavioral disorders in their lifetime in India we devote
less than 1% of our health budget to mental health. Over 90%
of people with mental illness are cared for within their
communities by their families and may never even receive a
diagnosis.
Dr. Margaret Chan, Director General of the World Health
Organization, in her message launching WHO's 2008 World
Health Day, 'Primary Health Care: Now More Than Ever', stated
that WHO's focus on primary health care grows both from her
personal conviction, and from an increased demand from Member
States.
Dr. Chan noted that the concept that health systems might
become more "equitable, inclusive and fair" is in itself
solid rationale for inserting the needs of people living with
mental health problems and disorders into the discussion of
improving integrated primary health care.
For centuries, mental health treatment, mental health
promotion and prevention of disorders have not received the
needed level of attention from governments, from the medical
profession, and from the general public.
STRENGTHENING MENTAL HEALTH PROMOTION
As a society we need to realize that mental health is
determined by multiple and interacting social, psychological,
and biological factors. Mental disorders can have an effect
on physical health and many physical ailments can induce more
mental health issues. It is imperative that mental health and
mental disorders are included in plans and policies intended
to promote the concept of "Primary Health Care now more than ever"
National mental health policies should recognize and address
the broader issues which promote mental health. This requires
mainstreaming mental health promotion into policies and
programmes in government and business sectors. Particularly
important are the decision-makers in governments at local and
national levels, whose actions affect mental health in ways
that they may not realize.
The 2009 World Mental Health Day global awareness campaign
theme "Mental Health in Primary Care: Enhancing Treatment and
Promoting Mental Health" is intended to address the
continuing need to "make mental health a global priority,"
and focus the integration of mental health into primary
healthcare.
The engagement of the "end users" of mental health services,
their families who carry much of the responsibility for
helping people living with mental illnesses, and the
advocates who attempt to influence mental health policies, is
critical.
Why integrate behavioral health into primary care settings?
Most people seek help for behavioral health problems in
primary care settings. Behavioral health problems often go
undetected and untreated in primary care. When psychiatric
disorders are not addressed in people with chronic medical
illnesses, they have worse psychiatric and medical outcomes.
Treating behavioral health problems in the primary care
presents an important opportunity to intervene early and
prevent more disabling disorders.
WHO/ World Organization of Family Doctors (WONCA) in 2008
described seven good reasons for integrating mental health
into primary care
1. Since the burden of mental disorders is great,
they create a substantial personal burden for
affected individuals and their families, and they
produce significant economic and social hardships
that affect society as a whole.
2. Mental and physical health problems are interwoven. Many
people suffer from both physical and mental health problems.
Integrated primary care services help ensure that people are
treated in a holistic manner
3. The treatment gap for mental disorders is enormous.
Primary care for mental health helps close the significant
gap between the prevalence of mental disorders, and the
number of people receiving treatment and care.
4. Primary care for mental health enhances access. When
mental health is integrated into primary care, people can
access mental health services closer to their homes, thus
keeping their families together and maintaining their daily
activities and facilitates community outreach and mental
health promotion, as well as long-term monitoring and
management of affected individuals.
5. Primary care for mental health promotes respect of human
rights. Mental health services delivered in primary care
minimises stigma and discrimination.
6. Primary care for mental health is affordable and cost
effective. Primary care services for mental health are less
expensive than psychiatric hospitals or seeking specialist
care in distant locations.
7. Primary care for mental health generates good health
outcomes. This happens particularly when linked to a network
of services at secondary level and in the community.
The way the services are offered can be in two ways:
1. The first model is characterized by keeping a separate
mental health day receiving patients in a designated area of
the primary or community health centre. 2. In the second
model, mental disorders are managed as any other health
problems in the centre.
Barriers which interfere with integrating care include :-
* Clinical barriers because of the differences in the culture
of both the health providers, lack of training, interest and
stigma.
* Organizational barriers include difficulties with
communication across physical and behavioral health
providers, and primary care's orientation to treating acute
problems.
* Policy barriers include legal obstacles/regulations to
sharing information across provider systems
* Financial barriers are complex and include many issues.
To overcome them WONCA advocates ten strategies for
integrating mental health in primary care :-
* Policy and plans need to incorporate primary care for
mental health.
* Advocacy is required to shift attitudes and behaviour.
* Adequate training of primary care workers is required.
* Primary care tasks must be limited and doable.
* Specialist mental health professionals and facilities must
be available to support primary care.
* Patients must have access to essential psychotropic
medications in primary care.
* Integration is a process, not an event.
* A mental health service coordinator is crucial.
* Collaboration with other government non-health sectors,
nongovernmental organizations, village and community health
workers, and volunteers is required.
* Financial and human resources are needed.
Some Personal recommendations for Goa
1. A substantial allocation of health budget for mental
health needs to be done for prevention, promotion and
rehabilitation
2. Counsellors need to be appointed at Primary Health Centre
level and trained on the issues.
3. Mental Health needs to be mainstreamed in private sectors
as well as all Government departments e.g. stress prevention
programmes)
4. Networking of all sectors is required for efficient
service delivery and to de-stigmatise the illnesses
5. A Special Gram Sabha can be held to discuss health every
year, so that a community level response is achieved and the
topic is destigmatised.
6. All Major Planning at the State level needs to Mental
Health Impact Assessment and the State Disaster Management
Unit needs to have psychological representation.
7. Our schools need follow the inclusive education model and
allow for differentially abled children
8. Remedial Teachers and School Counsellors, need to be
appointed in all schools
9. Mental Health should be part of the subjects taught, to
de-stigmatize the topic and promote mental hygiene.
10. Mental Health of our Senior Citizens should also be
prioritized with emphasis on care and education of lifespan
problems and their aging rights.
11. Like the Regional Plan a Village Wide Health Plan or
White Paper on Health needs to be prepared.
12. There needs to be special targeted interventions for
vulnerable groups. (e.g. after a disaster )
Come let us all celebrate World Mental Health Day by opening
our minds and remember there is No Health without Mental
Health!
* * *
Karl de Souza lives and works out of Moira, Goa.
