W

O
R
L
F
D
New understanding
H
E
A
Substantial burden O

L
T Effective care
C
H
R
Improving policies
E
P Reducing stigma U
O
R Multi-sector approach
T S
20 Increasing research
01
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Department of Mental Health and Substance Dependence, WHO Geneva 1 2001
W
O
R
L
O
D
• raise awareness of the real burden of mental B
H
E disorders and their costs in human, social and J
A
L economic terms. E
T C
H
T
R • help dismantle the barriers - particularly of
I
E stigma, discrimination, and inadequate services
P V
O - which prevent millions of people from
R receiving treatment. E
T S
20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 2 2001
W
O R
R
E
L
D C
O
H • core actions to be immediately undertaken
E M
A
to improve the mental health situation in M
L countries. E
T
N
H
D
R • describes how these actions are A
E
P
compatible with the reality of individual T
O country development. I
R O
T
N
20 S
01
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Department of Mental Health and Substance Dependence, WHO Geneva 3 2001
W
O T
R A
L B
D L
E
H • Message of the Director-General
E
A • Overview O
L F
T • A public health approach to mental health
H • Burden of mental and behavioural disorders C
R O
E • Solving mental health problems
N
P •
O
Mental health policy and service provision T
R • The way forward E
T N
20 T
01 S
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Department of Mental Health and Substance Dependence, WHO Geneva 4 2001
W
O
R
L

Defining mental health

D C
H
H
E A
A • Different meaning in various cultures P
L T
T
E
H • Includes subjective well-being, R
R
E
self-efficacy, autonomy, competence,
P self-actualization O
O
N
R
T • Broader than absence of mental disorders E

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 5 2001
W
O
R
L
D C

H
Defining mental disorders H
E A
A P
L T
T Combination of abnormal thoughts,
E
H
R
emotions, behaviour, and R

E
P relationships with others.
O
O
N
R
T E

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 6 2001
W
O
R
L
D C

H
New Understanding of H
A
E
A Mental Health P
L T
T Driven by: E
H
R
R
E • advances in neuroscience
P O
O • advances in behavioural medicine N
R
T E

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 7 2001
W
O
R
L
D C

H
Advances in Neuroscience: H
A
E
A Key Findings P
L T
T
H • Prenatally and throughout life, genes and E
environment are involved in a series of R
R
E interactions.
P O
O
R • Throughout life, every act of learning physically N
T changes the brain. E

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 8 2001
W
O
R
L
D Changing Understanding of the Brain C
H
H
E A
A P
L T
T
E
H
R
R
E
P O
O
N
R
T E

20

Fig 1.2
01
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Department of Mental Health and Substance Dependence, WHO Geneva 9 2001
W
O
R
L
D C
H
H
E A
Integration of neuroimaging and
A P
L
T
neurophysiology with molecular biology T
E
H
will lead to greater understanding of normal R
R
E
P
and abnormal mental functions,
O
O
R and more effective treatments. N
T E

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 10 2001
W
O
R
L
D
Advances in Behavioural Medicine: C
H
H
E Key Findings A
A P
L T
T Fundamental connection between
E
H mental and physical health: R
R
E
P – thought, feelings and behaviour influence O
O
R
physical illnesses N
E
T – physical health status influences mental
20 health and well-being
01
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Department of Mental Health and Substance Dependence, WHO Geneva 11 2001
W
O
R
L
D Psychological factors influence C
H
H
E physical illnesses A
A
L examples: P
T
T
E
H • Women with breast cancer who R
R receive supportive group therapy
E
P live longer. O
O
N
R
T • Depression predicts the incidence E

20 and outcome of heart disease.

01
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Department of Mental Health and Substance Dependence, WHO Geneva 12 2001
W
O
R
L
D C

H
New Understanding H
A
E
A Mental Health P
L T
T
E
H
Mental health is crucial to the overall well-being of R
R
E individuals, societies and countries.
P O
O
N
R
T E

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 13 2001
W
O
R
L
D New Understanding C
H
H
E
Mental Disorders A
A P
L • influenced by a combination of biological, T
T
H
psychological, and social factors E
R
R
E • have a physical basis in the brain
P O
O
R • can be treated effectively N
T E

20 Sufferers have new hope of living full and productive lives.

01
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Department of Mental Health and Substance Dependence, WHO Geneva 14 2001
W
O
R
L
D New Understanding C
H
H
E
Mental Disorders A
A P
L T
T Old Thinking:
E
H
• Genetics versus Environment R
R
E
P
O New thinking: O
N
R • Genetics plus environment E
T
20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 15 2001
W
O
R
L
D Continuum of depressive C
H
H
E
symptoms in the population A
A P
L T
T
E
H
R
R
E
P O
O
N
R
T E

20

Fig 1.3
01
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Department of Mental Health and Substance Dependence, WHO Geneva 16 2001
W
O
R
L
D Development of mental disorders - interaction of C
H biological, psychological and social factors H
E A
A
L P
T T
H Biological Psychological E
factors factors
R R
Mental and
E behavioural
disorders
P
O O
R N
T Social factors
E
20

Fig. 1.1
01
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Department of Mental Health and Substance Dependence, WHO Geneva 17 2001
W
O
R
L
D
Biopsychosocial relationship C
H
H
E examples: A
A P
L • Exposure to stress during early development is
T
T associated with depression later in life.
E
H
R
R • Behaviour therapy/interpersonal therapy for
E depression results in brain changes similar to
P
O
treatment with medication. O
N
R
T • Socio-economic status influences the onset and E

20 course of mental disorders.

01
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Department of Mental Health and Substance Dependence, WHO Geneva 18 2001
W
O
R
L
D C
H
H
E A
A We have at our disposal the P
L T
T knowledge and power to
E
H
R
significantly reduce the R

E
P burden of mental disorders, O
O
N
R world-wide.
T E

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 19 2001
W
O
R
L
C
D
H
Magnitude of mental disorders H
E A
A • 10-15% of adult population affected P
L T
T
E
H • 20% of patients seeking primary health
R
R care have one or more mental disorders,
E
P though not recognised
T
O
W
R • One in four families have at least one O
T
member with a behavioural or mental
20
01 disorder at any point in time.
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Department of Mental Health and Substance Dependence, WHO Geneva 20 2001
W
O
R
L
D Mental and behaviour disorders C
H
H
E in children and adolescents A
A P
L T
T
E
H
R
R
E
P T
O

Table 2.2
W
R
T O

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 21 2001
W
O
R
L Psychiatric disorders in primary health care C
D
H
help seekers H
E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

Table 2.1
20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 22 2001
W
O
R
L
D Burden of disease C
H
H % attributed to mental and behavioural disorders
E A
of total DALYs lost world-wide
A P
L T
T
H • 1990 10 % E
R
R
E
P
• 2000 12.3 % T
O
W
R
T • 2020 (projected) 15 % O

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 23 2001
W
O
R
L
D C

H DALY H
E A
A Disability Adjusted Life Years P
L T
T
H Sum of years of potential life lost due to E
R
R premature mortality and the years of
E
P productive life lost due to disability T
O
W
R
T O

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Department of Mental Health and Substance Dependence, WHO Geneva 24 2001
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O
R
L
D
Leading causes of DALYs C

H both sexes, all ages H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.2

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 25 2001
W
O
R
L
D
Leading causes of DALYs C

H males, all ages H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.2

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 26 2001
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O
R
L
D Leading causes of DALYs C

H females, all ages H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.2

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 27 2001
W
O
R
L
D Leading causes of DALYs C
H
H both sexes,15-44 years A
E
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.2

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 28 2001
W
O
R
L
D Leading causes of DALYs C

H males, 15-44 years H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.2

20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 29 2001
W
O
R
L
D Leading causes of DALYs C

H females, 15-44 years H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.2

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 30 2001
W
O
R
L C
C
D
H
DISABILITY H
H
A
E A
A • Mental and neurological conditions account P
P
T
L for 30.8% of all years lived with disability T
T E
H (YLD). E
R
R
R
E • Depression causes the largest amount of
P T
O disability(12%). T
W
W
R O
T O
• 6 neuropsychiatric conditions figure in the
20
01
top 20 causes of disability.
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Department of Mental Health and Substance Dependence, WHO Geneva 31 2001
W
O
R
L
D
Leading causes YLDs C

H both sexes, all ages H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.3

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 32 2001
W
O
R
L
D
Leading causes of YLDs C

H males, all ages H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.3

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 33 2001
W
O
R
L
D
Leading causes of YLDs C

H females, all ages H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.3

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 34 2001
W
O
R
L
D
Leading causes of YLDs C

H Both sexes, 15-44 years H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.3

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 35 2001
W
O
R
L
D Leading causes of YLDs C

H males, 15-44 years H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.3

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 36 2001
W
O
R
L
D
Leading causes of YLDs C

H females, 15-44 years H

E A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

From Fig. 2.3

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 37 2001
W
O
R
L
D
Economic impact of mental disorders C
H
H
E examples: A
A P
L • aggregate yearly cost in USA of $148 billion, T
T
H equal to 2.5% of gross national product E
R
R
E • expenditure as proportion of all health service
P T
O costs:
W
R – United Kingdom: 22%
T O
– Netherlands: 23%
20
01
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Department of Mental Health and Substance Dependence, WHO Geneva 38 2001
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O
R
L
D Mental Disorders: C
H
H
E Impact on Quality of Life (QOL) A
A P
L T
T • substantial and sustained negative impact E
H
R
R
E
• QOL continues to be poor even after recovery
P due to stigma and discrimination T
O
W
R
T • QOL poorer for those living in institutions as O

20 compared to those in community

01
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Department of Mental Health and Substance Dependence, WHO Geneva 39 2001
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O
R
L
D Burden of caring C
H
H
E • Economic difficulties A
A P
L T
T • Emotional stress
E
H
R
R • Disruption of household routine
E
P • Restriction of social activities T
O
W
R
T • Poor physical health O

20
01 • Stigma and discrimination
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Department of Mental Health and Substance Dependence, WHO Geneva 40 2001
W
O
R
L
D Depression C
H
H
E Burden A
A P
L • fourth leading cause of burden among T
T
H all diseases (4.4% of total DALYs) E
R
R
E • second leading cause among
P T
O 15-44 year age group (8.6% of DALYs)
W
R
T O
– among women in 15-44 year age group, the
20 amount reaches 10.6% of DALYs
01
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Department of Mental Health and Substance Dependence, WHO Geneva 41 2001
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O
R
L
D Schizophrenia C
H
H
E Burden A
A P
L T
T • third most disabling condition among
E
H 15-44 years age group (YLDs) R
R
E
P • about 10% of persons with schizophrenia die T
O by suicide W
R
T O

20 • reduces life span by an average of 10 years

01
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Department of Mental Health and Substance Dependence, WHO Geneva 42 2001
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O
R
L
D Epilepsy: Magnitude C
H
H
E 50 million people suffer world wide A
A 40 million of the 50 million live in developing countries P
L T
T

Source: The International League Against Epilepsy (ILAE) 1999

E
H
R
R
E
P T
O
W
R
T O

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Department of Mental Health and Substance Dependence, WHO Geneva 43 2001
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O
R
L
D
Burden of Alcohol Use Disorders C
H
H
E (DALYs) A
A P
L T
T • All Ages and both sexes 1.3 %
E
H
R
R • All ages, males 2.1 %
E
P T
O • 15-44 year olds,both sexes 3.0 % W
R
T O

20 • 15-44 year olds,males 5.1 %

01
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Department of Mental Health and Substance Dependence, WHO Geneva 44 2001
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O
R
L
D Suicide as a leading cause of C
H
H
E death in 15-34 year age group A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

20

Fig 2.5
01
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Department of Mental Health and Substance Dependence, WHO Geneva 45 2001
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O
R
L
D
Suicide Rate C
H
H
E A
A P
L 1996 T
T
H 15.1/100 000 population E
R
R
E
P Males: 24.0/100 000 T
O
R
Females: 6.8/100 000 W
T O

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 46 2001
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O
R
L
D Suicide Rates: C
H
H
E wide variations A
A P
L T
T Mexico: 3.4/ 100 000 (1993-1995) E
H
R
R
E
China: 14.0/100 000 (1996-1998)
P T
O Russian Federation: 34.0/100 000 (1996-1998) W
R
T O

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O
R
L
D Changes in suicide rates C
H
H
E
in mega countries A
A P
L T
T
E
H
R
R
E
P T
O
W
R
T O

20
01

Fig 2.4
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Department of Mental Health and Substance Dependence, WHO Geneva 48 2001
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O
R
L
D
SUICIDE C
H
H
E A
A P
L T
T • Variations in suicide rates must be
E
H considered in the cultural context. R
R
E
P • Epidemiological surveillance and T
O local research required to improve W
R
T preventive efforts. O

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O
R
L
D C

H Attempted suicide H
A
E
A P
L T
T
H
10-20 times higher than the E
R
R number of completed suicides
E
P T
O
W
R
T O

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Department of Mental Health and Substance Dependence, WHO Geneva 50 2001
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O
R
L
D C

H Determinants H
A
E
A Gender: Women and mental health P
L T
T
E
H • at greater risk due to multiple roles R
R
E
P • female to male ratio is 1.5 to 2: 1 T
O
W
R
T • greatest differences in adult life O

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01
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Department of Mental Health and Substance Dependence, WHO Geneva 51 2001
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O
R
L
D Determinants C
H
H
E
Domestic violence and contemplation of suicide A
A P
L T
T % of women who have ever thought of committing suicide
(P<0.001) E
H
R
R
E
P T
O
W
R
Table 2.3
T O

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O
R
L
D
Determinants C
H
H
E Disaster and mental health A
A P
L T
T
E
H Between a third and half of the R
R
E population experiencing a disaster
P T
O suffer from significant mental distress. W
R
T O

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01
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O
R
L
D Determinants C
H
H Vicious cycle of poverty and mental disorders A
E
A P
L T
T
E
H
R
R
E
P T
O
H
R
T R
E
20
E

Fig. 1.4
01
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Department of Mental Health and Substance Dependence, WHO Geneva 54 2001
W
O
R
L
D Determinants C
H
H
E Family A
A P
L T
T • Social and emotional environment E
H
within family plays a role in mental R
R
E
disorders.
P T
O • Effective changing of family W
R
T environment can reduce relapses O

20 in schizophrenia up to 77%.
01
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Department of Mental Health and Substance Dependence, WHO Geneva 55 2001
W
O
R
L
D
Comorbidity C
H
H
E Mental Disorders and Substance Dependence A
A P
L T
T
H • In alcohol /drug services, 30-90% have E
R
R a “dual diagnosis”.
E
P T
O • In mental health services, up to 65%
W
R have alcohol and drug use disorders. O
T
20
01
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O
R
L
D Solving Mental Health problems C
H
H the shifting paradigm A
E
A P
L Institutional care replaced by T
T community-based care largely due to: E
H
R
– evidence that people can be R

E successfully treated in their

P communities T
O
H
R – human rights movement
T R
– availability of improved E
20
01 interventions and treatments E

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O
R
L
D
The shifting paradigm C

H key mile stones H

E A
A • UN Principles for the protection of Persons P
L T
T with mental illness and the improvement of
E
H mental health care in 1991 R
R – rights of ill individuals
E
P T
O
• WHO/PAHO Caracas Declaration in 1994 H
R
T R
– development of psychiatric care closely E
20
01 linked with primary health care E

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Department of Mental Health and Substance Dependence, WHO Geneva 58 2001
W
O
R
L
D Elements of effective care C
H
H
E include A
A P
L T
T • early diagnosis and treatment E
H
R
R
E
• pharmacological, psychological and
P psychosocial interventions T
O
H
R
T • prevention, treatment and rehabilitation R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 59 2001
W
O
R
L
D Community-based care C
H
H
E
benefits A
A • services close to home P
L T
T • focus on disabilities as well as symptoms
E
H • focus on the individual R
R
E • wide range of services
P •
O
ambulatory rather than static services T
H
R • partnership with carers R
T
20
• better quality of life for ill persons E
E
01 • prevents inappropriate admissions
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Department of Mental Health and Substance Dependence, WHO Geneva 60 2001
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O
R
L
D De-institutionalisation C
H
H
E involves A
A P
L T
T
H • establishment and maintenance of E
R
R community support systems
E
P
• discharge to the community of long-term
T
O patients with adequate preparation H
R
T R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 61 2001
W
O
R
L
D
Primary Prevention C
H
H
E A
A P
L T
T
H
comprises measures to intercept the E
R
R causes of a disease before they
E
P
O
involve the individual to avoid the T
H
R
T occurrence of the condition R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 62 2001
W
O
R
L
D Secondary Prevention C
H
H
E
TREATMENT A
A P
L T
T refers to measures to arrest a disease E
H
R
R process already initiated, in order to
E
P prevent further complications and T
O
H
R sequel, limit disability and prevent death
T R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 63 2001
W
O
R
L
D Tertiary Prevention C
H
H REHABILITATION A
E
A P
L • involves measures aimed at disabled T
T individuals, restoring their previous E
H
situation or maximising the use of their R
R
E remaining capacities.
P T
O
R
• comprises both interventions at the level H
T of the individual and modifications of the R
E
20 environment
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 64 2001
W
O
R
L
D Effectiveness of interventions C
H
H
E for depression A
A P
L T
T
E
H
R
R
E
P Table 3.2
T
O
H
R
T R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 65 2001
W
O
R
L
D Effectiveness of interventions C
H
H
E
for schizophrenia A
A P
L T
T
E
H
R
R
E
P T
O
Table 3.3 H
R
T R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 66 2001
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O
R
L
D C

H
Make psychotropic medicines available H
E A
A P
L Newer Psychotropic Medicines T
T
E
H
R
The first generation psychotropic drugs R

E for the treatment of schizophrenia and

P depression are as effective as newer T
O
drugs, though the latter have decreased H
R
T R
side effects.
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 67 2001
W
O
R
L
D Effectiveness of interventions C
H
H
E for epilepsy A
A P
L T
T
E
H
R
R
E

Table 3.4
P T
O
H
R
T R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 68 2001
W
O
R
L
D Effectiveness of Treatment C
H
H
E for Drug Dependence A
A P
L T
T • reduces use by 40-60% E
H
R
R
E • comparable to success rates for
P diabetes, hypertension and asthma T
O
H
R
T R
(NIDA,2000) E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 69 2001
W
O
R
L
D Effectiveness of Treatment C
H
H
E
Depression A
A P
L Up to 60% of patients recover T
T Substance Abuse E
H
R
R Up to 60% reduction in drug use
E
P
Epilepsy
T
O
H
R Up to 73% of patients live free from seizures
T R
Schizophrenia E
20
01 Up to 77% of patients live without relapses E
a T mor F

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Department of Mental Health and Substance Dependence, WHO Geneva 70 2001
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O
R
L
D Determinants C
H
H
E HIV/AIDS A
A Co-morbidity with: P
L T
T – depression E
H
– cognitive deficits R
R
E – anxiety disorders
P T
O – drug dependence and injection drug use
H
R
T
– physical illnesses:TB,STIs,other R

20
infections E
01 E
complicates course and adherence to treatment
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Department of Mental Health and Substance Dependence, WHO Geneva 71 2001
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O
R
L
D EFFECTIVE C

H SUICIDE PREVENTION H
A
E
A • early recognition and treatment of depression, P
L T
T schizophrenia and alcohol dependence
E
H • training of general practitioners and primary R
R health care personnel
E
P • de-glamorising suicide T
O
• control of firearms and pesticides H
R
T R
• detoxification of domestic gases E
20
01 • life skills education in schools E

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O
R
L
D Needs of People with Mental Disorders C
H
H
E A
A P
L T
T
E
H
R
R
E
P T
O
H
R
T R
E
20

Figure 3.1
01 E

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O
R
L
D Poor utilisation of services C

H example from Australia 1997 H

E A
A P
L T
T
E
H
R
R
E
P T
O
H
R

Table 3.1
T R
E
20
01 E

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Department of Mental Health and Substance Dependence, WHO Geneva 74 2001