The world health report 2001 : mental health : new understanding, new hope.

CONTENTS MESSAGE FROM THE DIRECTOR-GENERAL ix OVERVIEW xi Three scenarios for action xiii Outline of the report xiv CHAPTER 1 A PUBLIC HEALTH APPROACH TO MENTAL HEALTH 1 Introduction 3 Understanding mental health 5 Advances in neuroscience 5 Advances in behavioural medicine 7 Understanding mental and behavioural disorders 10 Biological factors 11 Psychological factors 12 Social factors 13 An integrated public health approach 16 CHAPTER 2 BURDEN OF MENTAL AND BEHAVIOURAL DISORDERS 19 Identifying disorders 21 Diagnosing disorders 21 Prevalence of disorders 23 Disorders seen in primary health care settings 23 Impact of disorders 24 Economic costs to society 26 Impact on quality of life 29 Some common disorders 29 Depressive disorders 29 Substance use disorders 30 Schizophrenia 33 Epilepsy 34 Alzheimer's disease 34 Mental retardation 35 Disorders of childhood and adolescence 36 Comorbidity 37 Suicide 37 Determinants of mental and behavioural disorders 39 Poverty 40 Sex 41 Age 43 Conflicts and disasters 43 Major physical diseases 44 Family and environmental factors 44 CHAPTER 3 SOLVING MENTAL HEALTH PROBLEMS 47 The shifting paradigm 49 Principles of care 54 Diagnosis and intervention 54 Continuity of care 55 Wide range of services 55 Partnerships with patients and families 56 Involvement of the local community 58 Integration into primary health care 59 Ingredients of care 59 Pharmacotherapy 61 Psychotherapy 61 Psychosocial rehabilitation 62 Vocational rehabilitation and employment 63 Housing 64 Examples of effectiveness 64 Depression 64 Alcohol dependence 66 Drug dependence 67 Schizophrenia 68 Epilepsy 69 Alzheimer's disease 70 Mental retardation 71 Hyperkinetic disorders 71 Suicide prevention 73 CHAPTER 4 MENTAL HEALTH POLICY AND SERVICE PROVISION 75 Developing policy 77 Health system and financing arrangements 78 Formulating mental health policy 80 Establishing an information base 81 Highlighting vulnerable groups and special problems 82 Respecting human rights 83 Mental health legislation 84 Providing services 85 Shifting care away from large psychiatric hospitals 87 Developing community mental health services 88 Integrating mental health care into general health services 89 Ensuring the availability of psychotropic drugs 91 Creating intersectoral links 92 Choosing mental health strategies 92 Purchasing versus providing: public and private roles 94 Developing human resources 95 Promoting mental health 97 Raising public awareness 98 Role of the mass media 98 Using community resources to stimulate change 99 Involving other sectors 101 Labour and employment 101 Commerce and economics 102 Education 103 Housing 103 Other social welfare services 103 Criminal justice system 103 Promoting research 104 Epidemiological research 104 Treatment prevention and promotion outcome research 104 Policy and service research 105 Economic research 105 Research in developing countries and cross-cultural comparisons 106 CHAPTER 5 THE WAY FORWARD 107 Providing effective solutions 109 Overall recommendations 110 Action based on resource realities 112 REFERENCES 117 STATISTICAL ANNEX 129 Explanatory notes 130 Annex Table 1 Basic indicators for all Member States 136 Annex Table 2 Deaths by cause, sex and mortality stratum in WHO Regions, estimates for 2000 144 Annex Table 3 Burden of disease in disability-adjusted life years (DALYs) by cause, sex and mortality stratum in WHO Regions, estimates for 2000 150 Annex Table 4 Healthy life expectancy (HALE) in all Member States, estimates for 2000 156 Annex Table 5 Selected National Health Accounts indicators for all Member States, estimates for 1997 and 1998 160 VI LIST OF MEMBER STATES BY WHO REGION AND MORTALITY STRATUM 168 ACKNOWLEDGEMENTS 170 INDEX 171 TABLES Table 2.1 Prevalence of major psychiatric disorders in primary health care 24 Table 2.2 Prevalence of child and adolescent disorders, selected studies 36 Table 2.3 Relationship between domestic violence and contemplation of suicide 42 Table 3.1 Utilization of professional services for mental problems, Australia, 1997 53 Table 3.2 Effectiveness of interventions for depression 65 Table 3.3 Effectiveness of interventions for schizophrenia 68 Table 3.4 Effectiveness of interventions for epilepsy 69 Table 4.1 Effects of transferring functions of the traditional mental hospital to community care 89 Table 4.2 Intersectoral collaboration for mental health 102 Table 5.1 Minimum actions required for mental health care, based on overall recommendations 114 FIGURES Figure 1.1 Interaction of biological, psychological, and social factors in the development of mental disorders 4 Figure 1.2 Understanding the brain 6 Figure 1.3 The continuum of depressive symptoms in the population 11 Figure 1.4 The vicious cycle of poverty and mental disorders 14 Figure 1.5 Average female/male ratio of psychotropic drug use, selected countries 15 Figure 2.1 Burden of neuropsychiatric conditions as a proportion of the total burden of disease, globally and in WHO Regions, estimates for 2000 26 Figure 2.2 Leading causes of disability-adjusted life years (DALYs), in all ages and in 15-44 year-olds, by sex, estimates for 2000 27 Figure 2.3 Leading causes of years of life lived with disability (YLDs), in all ages and in 15-44 year-olds, by sex, estimates for 2000 28 Figure 2.4 Changes in age-standardized suicide rates over specific time periods in countries with a population over 100 million 38 Figure 2.5 Suicide as a leading cause of death, selected countries of the European Region and China, 15-34 year-olds, 1998 39 Figure 2.6 Prevalence of depression in low versus high income groups, selected countries 40 Figure 3.1 Needs of people with mental disorders 60 Figure 4.1 Presence of mental health policies and legislation, percentage of Member States in WHO Regions, 2000 79 Vll Figure 4.2 Barriers to implementation of effective intervention for mental disorders 85 Figure 4.3 Number of psychiatric beds per 10 000 population by WHO Region, 2000 86 Figure 4.4 Number of psychiatrists per 100 000 population, 2000 96 Figure 4.5 Number of psychiatric nurses per 100 000 population, 2000 97 BOXES Box 1.1 The brain: new understanding wins the Nobel Prize 7 Box 1.2 Pain and well-being 8 Box 1.3 Adhering to medical advice 9 Box 2.1 Mental and behavioural disorders classified in ICD-10 22 Box 2.2 Global Burden of Disease 2000 25 Box 2.3 Tobacco use and mental disorders 31 Box 2.4 Poor people's views on sickness of body and mind 41 Box 3.1 Mental care: then or now? 50 Box 3.2 Human rights abuse in psychiatric hospitals 51 Box 3.3 The Declaration of Caracas 52 Box 3.4 The role of consumers in mental health care 56 Box 3.5 Partnerships with families 57 Box 3.6 Work opportunities in the community 63 Box 3.7 Caring for tomorrow's grandparents 70 Box 3.8 Two national approaches to suicide prevention 72 Box 4.1 Project Atlas 78 Box 4.2 Formulating policy: the key questions 80 Box 4.3 Mental health reform in Uganda 81 Box 4.4 Mental health reform in Italy 86 Box 4.5 Mental health reform in Australia 87 Box 4.6 Mental health services: the urban-rural imbalance 88 Box 4.7 Integration of mental health into primary health care 90 Box 4.8 Intersectoral links for mental health 92 Box 4.9 Fighting stigma 99 Box 4.10 The Geneva Initiative 100