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HEALTH PROMOTION IN health promotion is also necessary in focusing on their health rather than their
SCHIZOPHRENIA addition to prevention. In fact it becomes illness. By doing so, they enhance their
Dr Nikos Christodoulou,
even clearer how necessary it is if we just ability to achieve psychological well-being
Prof Dinesh Bhugra listen to what people who suffer from and also cope with adversity9.
schizophrenia actually want: They do want While this approach can yield great
to get on with their lives which means rewards for people with schizophrenia,
Introduction having jobs, friends, housing and money managing to adhere to it is easier said
The World Health Organisation denes even if they continue to have symptoms. than done. The difculty lies in that
health as a state of complete physical, The challenge for psychiatrists is to one needs to keep their illness at bay
mental, and social well-being and combine treatment as well as prevention while focusing on the positive aspects
not merely an absence of disease or but equally important to advocate for our of their life. Keeping the illness at bay is
inrmity1. This denition captures two patients and help promote mental health. complicated by the fact that schizophrenia
crucial points: Listening is only one part of is one of the few illnesses that affect the
Firstly it emphasises that mental health is communication between the clinicians persons ability to recognise that they, in
an inseparable part of a persons holistic and their patients; the other is delivering a fact, have an illness. Lacking that insight
well-being, together with physical and clear message which is easily understood: makes people believe that they dont
social health. This latter point of the We aim to do just that in this piece. need therapy, be that with medications
indivisibility of body and mind is ancient; This is hopefully a clear and informative or any other kind, and slowly but surely
mens sana in corpore sano (healthy introduction to health promotion in the illness returns with a vengeance. This
mind in a healthy body)2 and also  schizophrenia. It is written for a wide tension can create major problems with
 audience, including those who suffer from carers as well as health care professionals.
 the illness, their carers and families, and That is why it is very important for people
( Who is happy? He who healthcare professionals alike. with schizophrenia to remember that, in
has a healthy body, a resourceful soul and addition to their own individual strengths
Illness Prevention and Health
a docile nature)3. In addition to notable and virtues, they also have an illness that
Promotion in Schizophrenia
elaborations in the literature4,5, recent needs to be tamed in the same way as
years have seen the elevation of this Schizophrenia is one of those life- other chronic conditions are managed.
philosophical stance into a campaign, for changing illnesses, but it does not have
to be life-dening. Just like people with Focusing both on prevention and
instance the No health without mental promotion can serve to help in multiple
health campaign, endorsed by the World diabetes, hypertension, rheumatoid
arthritis or heart disease, people with ways: Improving ones health can lead to
Psychiatric Association, the Royal College preventing mental illness and vice versa.
of Psychiatrists and the Department schizophrenia frequently have to keep
their illness at bay with medications, life- As shown in the case of depression10,
of Health for England, among others.
style changes or psychological therapies people with low positive health can be
Promoting mental and physical health
or a combination of those. But beyond vulnerable to illness, and conversely, by
together is the right thing to do, especially
illness, and certainly more importantly, increasing positive mental health one
in schizophrenia, especially if one takes
people with schizophrenia have a life to may also manage to prevent illness11.
into account the physical co-morbidity
live and enjoy. It may be with small steps Using prevention and promotion makes
associated with it. However, in the past
initially, but focusing on the positive logical sense; on the one hand prevention
it has been noted that mental illness
aspects of ones life builds on strengths is better than cure, and on the other
prevention and mental health promotion
and leads to an upward spiral of positivity. hand improving ones life is an end
have received less attention than the
By focusing on this - the positive and in itself. Furthermore, mental illness
physical health needs of people with
healthy aspects of their life people who prevention and mental health promotion
mental illness6.
suffer from schizophrenia begin to gain are supported by mounting evidence on
Secondly, the WHO denition asserts that condence and self-esteem and become their effectiveness and cost-effectiveness,
illness prevention is necessary, but not more independent and empowered which is reected in the fact that they
enough to achieve health7. This concern in their life. Eventually, they can start have been endorsed by major bodies such
is underpinned by the fact that psychiatry dening their life and themselves as as the European Parliament12 and the
has focused on illness rather than well- persons rather than patients and start World Health Organisation13.
being and good functioning8; indeed,
Health Promotion May Be the almost by denition it is very difcult Health promotion in schizophrenia is
Most Important Intervention in to catch it early. Regardless of that, important not only for the individual,
Schizophrenia preventing relapses and consequences but also for society as a whole. There is
Some people with schizophrenia of the illness (secondary and tertiary good evidence suggesting that illness
experience a gradual decline in their prevention) can be useful, as preventing prevention and health promotion
ability to function at a high level. This relapses also prevents further functional measures in schizophrenia may be both
is due to a number of factors some of deterioration, and consequently improves clinically effective and cost-effective19.
which are intrinsic to schizophrenia, quality of life. Although the usefulness of Although nancial considerations should
including, for example disorganisation prevention may be rather limited for those not come into play at the clinical setting,
and depression, but others are to do who have already had functional decline, one cannot escape the realisation that
with stigma and social exclusion. For health promotion can still play a key role. cost-effectiveness coupled with re-
those who experience it, this functional In order to improve quality of life for investment can improve mental healthcare
decline can be very frustrating, especially patients, a different approach is needed, for all.
as it is often persistent. Treating and that would be to reinforce those
schizophrenia appropriately means factors in a persons life that would
that some of the symptoms may go Conclusion
empower them to build on their own
away, but even that does not guarantee strengths and improve their quality of life, In conclusion, health promotion may be
that the persons life experience will regardless of the state or stage of their considered to be the most important
improve. A characteristic example of this illness. Health promotion can be applied intervention in schizophrenia as it can
is depression in schizophrenia: There is way before the illness manifests itself benet everyone20, regardless of the state
some older evidence suggesting that and will contribute towards primary and or stage of their illness, can be applied
depression can be a good prognostic secondary prevention as a bonus effect. to the wider population, can offer an
factor for schizophrenia. Indeed, this is An excellent example is Early Intervention improvement in quality of life as opposed
often seen in clinical practice, where an in psychosis, a practice that has great to the mere absence of illness, and can
affective component may predict better potential not only for preventing the be cost-effective and therefore indirectly
response to medications. However, more onset of frank illness for young people benecial for the health of many more
recent evidence suggests that, while the with prodromal symptoms, but also for people. Given the evidence, mental health
presence of depression may be good longitudinally inuencing their health professionals need to embrace mental
for the prognosis of the illness, it is not and quality of life17. Even for those who health promotion. However it appears
good for the person, as it is associated will not go on to develop schizophrenia, that often this is not the case21. More
with poorer recovery14, more relapses15 population-targeted mental health effort is therefore required, particularly
and generally a drop in quality of life16. promotion can lead to an improvement in order to communicate this message to
In other words, treating schizophrenia in in well-being and quality of life. Being mental health professionals, but also to
these cases may be relatively easier but aware of the stressors which can cause patients and their carers and families. To
regardless of whether the treatment is any number of psychiatric illnesses and this end, the role of the World Federation
successful or not, the person still suffers relapses can help a person. Focusing of Mental Health is very important and its
with a lower quality of life. on promoting health in addition to Mental Health Day is a pivotal event.
Therefore, as demonstrated in the case preventing/treating the illness allows us to
of depression in schizophrenia, treating achieve an improvement in quality of life
the illness is not enough to achieve true irrespective of the illness. References
quality of life. Preventing the illness A very important conceptual point that 1. WHO. The World Health Organization Quality
from occurring in the rst place (primary of Life assessment (WHOQOL): position Paper. Soc
emerges from this approach is that Sci Med. 1995;41:14031409.
prevention) would be a very attractive focusing on the promotion of mental 2. Juvenal. In:Saturae, Liber IV, Satura X, 356.
option, as symptoms and functional health allows us to consider the person 3. Thales. In:Diogenes Lartius, (R. D. Hicks, ed.),
decline would not have developed yet not the illness as the central and Lives of Eminent Philosophers I:37.
in these early stages. However, as a most important entity. Indeed, person- 4. Kalra, G., Natarajan, P., Bhugra, D. Migration
practical matter, in most cases prevention centred medicine itself has developed and physical illnesses (2011) Migration and mental
in schizophrenia is tackled at a secondary health, pp. 299-312.
into an important champion of mental
or tertiary level, i.e. once the disorder has 5. Christodoulou GN, Kontaxakis VP (eds, 1994).
illness prevention and mental health Topics in Preventive Psychiatry. Basel, Karger.
already taken hold or has already caused promotion18. Focusing on the person 6. Herrman H. The need for mental health
symptoms and/or functional decline. rather than the illness and applying promotion. Aust N Z J Psychiatry. 2001;35:709
In fact, one of the main difculties in mental health promotion equally to both 715.
recognising schizophrenia at primary the healthy and the ill, helps to push back 7. WHO. Mental Health Action Plan for Europe:
preventive level is that it is exactly those Facing the Challenges, Building Solutions.
against the stigma associated with mental Helsinki, Finland: World Health Organization;
symptoms that reveal it, and therefore illness and psychiatry. 2005.

8. Ryff CD, Singer B. Psychological well-being:
meaning, measurement, and implications for
psychotherapy research. Psychother Psychosom.
9. Kalra G, Christodoulou G, Jenkins R, Tsipas V,
Christodoulou N, Lecic-Tosevski D, et al. Mental
health promotion: Guidance and strategies. Eur
Psychiatry. 2012;27:8186.
10. Wood AM, Joseph S. The absence of positive
psychological (eudemonic) well-being as a risk
factor for depression: a ten year cohort study. J
Affect Disord. 2010;122:213217.
11. Burton NW, Pakenham KI, Brown WJ.
Feasibility and effectiveness of psychosocial
resilience training: a pilot study of the READY
program. Psychol Health Med. 2010;15:266277.
12. European Parliament Resolution of
19 February 2009 on Mental Health. P6
TA[2009]0063. Available at http://www.europarl.
13. World Health Organization: Summary
report: Prevention of mental disorders - effective
interventions and policy options. Geneva: World
Health Organization 2004.
14. Resnick SG, Rosenheck RA, Lehman AF. An
exploratory analysis of correlates of recovery.
Psychiatr Serv. 2004;55(5):540547.
15. Tollefson GD, Andersen SW, Tran PV. The
course of depressive symptoms in predicting
relapse in schizophrenia: a double-blind,
randomized comparison of olanzapine and
risperidone. Biol Psychiatry. 1999;46(3):365373.
16. Reine G, Lancon C, Di Tucci S, Sapin C,
Auquier P. Depression and subjective quality of
life in chronic phase schizophrenic patients. Acta
Psychiatr Scand. 2003;108(4):297303.
17. Christodoulou GN, Christodoulou NG. Early
Intervention in Psychiatry. Launching editorial in:
Early Intervention in Psychiatry 2007;1:5-6.
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The paradigm shift from a disease-centred to a
person-centred preventive medicine. Contribution
in: Manifeste pour une Mdecine de la Personne
[French]. France 2012:47-55.
19. Christodoulou NG, Christodoulou GN.
Financial crises: impact on mental health and
suggested responses. Psychother Psychosom.
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Promotion and Illness Prevention: A Challenge
for Psychiatrists. Psychiatry Investig. 2013
21. Monshat K, Herrman H. What does mental
health promotion mean to psychiatry trainees?
Australas Psychiatry. 2010;18:589.

Dr Nikos Christodoulou
Assistant Professor in Psychiatry
University of Nottingham Medical School
United Kingdom

Prof Dinesh Bhugra

Professor of Mental Health and Cultural Diversity
Health Service and Population Research
Institute of Psychiatry, Kings College London
United Kingdom

SCHIZOPHRENIA & SOCIAL mental health services over the previous Social inclusion is a meaningless
INCLUSION 12 months. In fact you are 14 times more term unless we break it down into
likely to be the victim of violence than the its component parts. It is not just
John Bowis
perpetrator. communication and outreach services,
Just imagine you have been to your GP although it may involve both. It is listening
Looked at another way, 99.97 per cent of
(primary care doctor in the UK General and respecting and assuming a can-do
people suffering from schizophrenia will
Practitioner) and he has made a diagnosis ability on the part of the individual or a
not be convicted of serious violence in a
and you go round to the pub or back to could-do one, if obstacles were removed
given year.
work and say to your friends or colleagues and encouragement given.
Do you know what Ive just been told I And yet, while an NHS (UK National
Health Service) survey on attitudes to It is opening doors to advice and
have got schizophrenia.
mental illness in 2011 showed that 77 advocacy; it is making possible
Do they rally round, put an arm round you, opportunities to work or to volunteer,
per cent of people agreed that mental
buy you a drink, tell you their granny had it, to take as much responsibility as feels
illness is an illness like any other, only 25
reassure you that there are good treatments comfortable for now; it means educating
per cent agreed with the statement that
for it nowadays and tell you to keep in media, communities, employers, trade
most women who were once patients
touch and let them know how you get on? unions, police, health professionals and
in a mental hospital can be trusted as
Or do they go silent, avert their gaze, babysitters. managers and policymakers to revise
remember they have a meeting to get to, old assumptions and old prejudices; it
The second assumption is that you cannot means ensuring the law, regulations
slink away to phone home and tell their
be treated or cured and so you should and procedures are reviewed and made
spouse not to let the children go to your
not be out of a hospital. The reality is that relevant; it means treating co- and multi-
home anymore?
some 25% of people with schizophrenia morbidities; it means having a benets
Or do you not go to the pub or back to do recover fully, a further 25-35% system and housing provision that help
work or anywhere you might meet your improve considerably and live relatively recovery and stability and it means caring
former friends and colleagues, because independent lives, some 20% improve but for the carers and assessing their needs.
youre scared scared about your need extensive support and between 10
condition and scared about their reaction? and 15% remain unimproved in hospital. It means all of us posing the question to
A further 10-15% will die prematurely, ourselves: If it is me or my child or my
Schizophrenia is a no-go word; it is a spouse or partner, what would I fear,
word that spells stigma stigma from the mostly by suicide.
what would I hope for and how could I be
rest of the world and stigma from inside I have met many people who live with the helped to cope?
you. No wonder campaigns are running condition. Some have been in hospital,
to change the terminology although some have been living independently in John Bowis
Im not sure the proposal of Psychosis the community, some with their families, WFMH Advisor
Susceptibility Syndrome is quite the de- some have served with me on NGO Former UK Member of Parliament and Health
stigmatising alternative we seek. Minister
boards and some are holding down
Member of the European Parliament and
Whatever we call it, we need to de- responsible and demanding jobs. Some Spokesman on Environment, Health & Food Safety
demonize it, if we are to succeed in have few symptoms and some have Honorary Fellow of the Royal College of
overpowering ones. They range across Psychiatrists
bringing social inclusion to those who live
with it. the list of positive symptoms, such as
hallucinations and delusions, to negative
The rst assumption is that you are ones, such as withdrawal and lack of
dangerous. The media choose to portray motivation, to cognitive decit, such as
your condition as violent and a risk to loss of attention span and these are well
people in the street. The reality is that described in the Backgrounder sheet you
few have violent episodes and most of will have seen.
those are cases of self-harm. In the UK we
have some 250,000 diagnosed cases. Of The lm A Beautiful Mind gave a vivid
the 5,189 homicides in Britain over nine experience of living with voices, of
years between 1997 and 2005, only some withdrawal, of family confusion and of
510, or 10 per cent, were committed by ultimate hope, which certainly reected
people who had been in contact with the the lives and emotions I have met.
The key message from my experience and
from that lm is that this is a condition
which can be managed and self-managed
with supportive treatment, social care and
with doors opening to social inclusion and
not slamming shut through the ignorance
of pre-judging and stigma.

THE ROLE OF GOVERNMENT be effectively cared for without fully select the goals and lifestyle practices that
AND CIVIL SOCIETY IN engaging them in their own health. they value and should be cared for by
Consequently, we believe that bold new services responding to their needs, goals,
approaches to health promotion and and values. Chronic diseases, the services
SCHIZOPHRENIA illness intervention need to be developed that seek to tackle them, and their wider
Juan Mezzich, MD, PhD and integrated in our health systems. economic impact ultimately involve
WFMH Vice-President for Governmental Affairs
Furthermore, the patient needs to persons, each with a unique life story,
Person-centered care offers a promising remain at the heart of these approaches. and a unique outlook on life. This shapes
approach to care for people experiencing Effective public health, clinical, medicinal their lifestyle colored by their experiences
schizophrenia and other chronic and technological procedures must be and environments, including the course
conditions, as it places the person in developed and implemented having the of their diseases and associated risk and
context at the center of health care whole person at the core within a broad protective factors.
rather than considering such persons as biological, psychological and socio-cultural Effective prevention and treatment of
just carriers of illness. Person-centered framework. diseases should monitor and promote
care, by emphasizing a holistic health
Around a third of the worlds population well-being, and should not be reduced to
framework and a recovery-oriented
currently suffers from at least one chronic symptomatic treatment and prevention
approach, is not only more likely to be
disease. More than 60% of deaths of diseases and their risk factors, as
effective on a sustained basis but also may
in 2008 resulted from cardiovascular, recognized by WHOs denition of
help de-stigmatize the persons affected
cancer, diabetes and respiratory illnesses. health. Attention to health promotion
and those who care for them. Heath care
A quarter of these deaths occurred is also important to motivate adherence
under this perspective is the responsibility
in people under the age of 60. Other to treatment. People are more easily
of all involved, i.e., patients, families,
chronic diseases such as mental and convinced to maintain actively their well
health professionals, non-governmental
musculoskeletal conditions have being than to restrain from unhealthy
organizations (such as the World
disproportionally high disease burden. practices leading to disease onset and
Federation for Mental Health) as well as
Death and disability have a devastating chronicity.
governmental and inter-governmental
effect on individuals, their families, and Such a framework of health promotion
the societies they live in, with wide and illness intervention should take full
Relevant to this approach is the 2012 economic consequences. account of the patients life goals, values,
Geneva Declaration on Person-centered
Four essential components of an stories and aspirations. The application
Care for Chronic Diseases which emerged
effective approach to chronic and non- of the person-centered approach should
from the 5th Geneva Conference on
communicable diseases are: always be empathetic, respectful and
Person-centered Medicine (in which the
1.Monitoring both risk and protective empowering to enhance the persons
WFMH along with the World Health
factors (intrinsic and extrinsic; biological, functioning, resilience, and well being
Organization, the International Alliance of
psychological, and social) through joint understanding and joint
Patients Organizations and a large group
decision making for clinical care and
of global health institutions participate). 2.Monitoring well-being, including health-promotion.
It was released by the International outcomes for positive health (vitality and
College of Person Centered Medicine and resilience despite exposure and adversity) Thus, the 5th Geneva Conference on
published in the International Journal of and illness (morbidity and disease-specic Person-Centered Medicine issues the
Person Centered Medicine (Vol 2, pages mortality) following recommendations:
153-154, 2012). It is presented below Governments should adopt a
with permission. 3.Individual and population-level
responses to engagement in health comprehensive person- and people-
The 21st century is emerging as the promotion (utilization of resources centred approach to integration
century of person-centered care, and for health promotion, adherence to of health promotion and illness
this perspective is especially compelling prevention programs, level of knowledge intervention to prevent and control
concerning chronic diseases. As the of effective health promotion and chronic diseases. To achieve this,
World Health Organization and the maintenance practices, as well as governments should invest in their
United Nations have recently documented obstacles and resources needed for their health systems recognizing that
and proposed, every government and actual application in life) investment in peoples health is
component of society needs to act now investment in social welfare, economic
to combat the growing epidemic of 4.Health system responses to illness prosperity and security.
chronic and non-communicable diseases (policies and plans, infrastructure,
human resources and access to essential The health sector has a responsibility
that threaten the lives and quality of to champion this, and to ensure that
living for so many people around the healthcare including medicines and other
therapies) health systems are able to engage and
world. What we must emphasize now is respond to the growing burden of
that a person-centered approach to the It should never be forgotten that people chronic diseases. Health services must
promotion and care of health is crucial have risk and protective factors; that also be engaged to prevent, diagnose,
to counteract this massive epidemic. people experience vitality and resilience, and treat these diseases through
People with chronic diseases cannot morbidities and disabilities; that people the integration of primary care,
multidisciplinary specialist services, and
public health.
Person- and people-centred care should
be supported by a close collaboration
between clinical care and public health.
Each person with a chronic disease
should be fully engaged in partnership
to achieve joint understanding and
joint decision making to prevent and
treat such diseases.
Health professional organizations must
work with their members to advance
person-centered health promotion
and care. It should also ensure the
integration of health and social
Person-centered public education,
professional training and health
research are crucial to support
effectively clinical care and public
health actions for chronic diseases.
Last but not least, civil society in
general must be engaged in efforts
to tackle chronic diseases, as the
effectiveness of these efforts will
largely rest on the commitment of
every person and component of society
Juan E. Mezzich, MD, PhD
Professor of Psychiatry, Icahn School of Medicine
at Mount Sinai, New York, USA