Improvement involves educators, among others. (Mental Health).

While programmes directed at improving physical health have had remarkable success in many parts of the world, mental health has been neglected. This neglect is all the more serious in view of the large and growing burden that mental disorders cause for individuals and the community. Social and economic development can also threaten mental health unless action is taken to avoid and reverse this. Most importantly, our knowledge is sufficient to take action, to reduce the burden and improve mental health through health promotion.' However, people in many countries and in different cultures remain convinced about the relevance of mental health to their own situations.

Partnerships between global and local communities can help make mental illness and mental health the business of everybody. The widely held opinion that this illness is a problem of the wealthy or the western world could not be further from reality. The World Health Report 2001 presents evidence that in all countries, whether rich or poor, mental illness is linked with poverty and the disadvantaged. There are new and effective treatments, including medicines for depression, psychosis and epilepsy, as well as psychological and social therapies, but they reach few of those who require them. Suicide is an important public health problem closely linked to mental health and is a major cause of mortality, especially for people living with mental disorders, affected adversely by alcohol and drugs and suffering social and economic stress.

The global community can contribute to local change by persuading decision-makers and the public that mental health is important and that change is possible. Improving mental health requires its promotion, as well as the prevention and treatment of disorders. The activities underpinning these are different from each other, but all depend on local information and research to support their planning and evaluation, for which international links and partnerships are again vital.

Mental health is the foundation for the well-being and effective functioning of individuals. It is more than the absence of mental disorder. It is the ability to think and learn, and to understand and live with one's own emotions and the reactions of others. It is a state of balance, with physical, psychological, social, cultural and spiritual contributions. (2) The links between mental and physical health are intimate and relevant in many ways to public health planning.

Mental health and the risk of mental disorders in a community are each influenced, for better and worse, by social and economic conditions. Rapid change and social and economic instability are apparent in many countries, some of which are related to global economic changes. Continued or growing impoverishment affects broad groups of rural and poorly educated people. Disasters, violence, displacement, urbanization, underemployment and family disruption are widespread. This is reflected in more discontent, more disturbed behaviour and more intolerance. These factors are associated with increased rates of mental disorders, including depression, anxiety, alcohol and substance abuse, as well as a decline in overall mental health. People become more likely to develop illness and less able to cope with its effects individually and in the family. The impact of these factors also makes it harder to gain access to health services because of cost, distribution or stigma.

Population growth and increased survival at all stages of life also mean that more people in developing and developed countries are reaching the age groups at risk for mental disorders. This includes adolescents and young adults-the age groups at risk for schizophrenia and common mental disorders, such as depression, and substance abuse--as well as older people, at risk for dementia. Families as primary caregivers receive insufficient support from services.

This situation requires dedicated action over a long period and the setting of priorities in each country and locality. Many countries recognize the value of a national strategy, which includes advocacy for the value of mental health, the development of services for those with mental disorders, approaches to broad-based mental health promotion, policy and legislation to support each of these, and support for local research.

Most countries still consign people with mental disorders to large isolated institutions. This influences attitudes and impedes appropriate service development, including support for the treatment of mental disorders in primary health care. Alliances are needed between mental and general health-care providers and community resources for disability support. Inadequate emphasis has been placed on early intervention and prevention. Poor access to effective treatments for depression, psychosis and epilepsy means that avoidable disabilities often afflict people from an early age and then persist into later life. Public health programmes can prevent epilepsy and intellectual disability associated with brain damage from trauma, infection and malnutrition.

Mental health professionals and services have a direct role in identifying and intervening in primary care with groups at risk of depression and alcohol abuse. Governments are also urged to consider mental health within their multisectoral plans for health promotion, raising its position in the scale of values of people and societies, so that decisions taken by Government and business will improve rather than compromise it. Mental health can be improved when policy makers in education, welfare, housing, employment and health sectors make decisions resulting in better social connection, reductions in discrimination on grounds of race, age, gender or health, and improved economic participation. (3)

Governments, in consultation with other partners and organizations, can consider investing in programmes for vulnerable populations, such as young people, the elderly, rural and indigenous populations, and displaced or immigrant communities. Through defined settings, such as schools and workplaces, activities may be coordinated between several sectors overtime, with a view to achieving, for example, better social connection and reduced discrimination and violence. Important examples include interventions to support families in improving the care of children and reducing the chances of child neglect and abuse, examination of the culture of bullying in schools, investigation of the use and conditions of labour, and care of older persons.

The integration of mental health into health care, particularly primary health care, will call for continued management of change over the years ahead, and the integration of their promotion will require a shift in thinking and community values. However, local communities are increasingly aware of the influence of community action on mental health. The knowledge, tools and strategies are now available and can be used in partnership with the United Nations and other global organizations.

Notes

(1.) World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva, World Health Organization.

(2.) Sartorius N. Universal strategies for the prevention of mental illness and the promotion of mental health. In: Jenkins R, Ustun TB, eds. Preventing Mental Illness: Mental Health Promotion in Primary Care. Chichester, UK, John Wiley, 1998.

(3.) Sartorius op cit; Victorian Health Promotion Foundation 1999, Mental health promotion plan, www.vichealth.vic.gov.au

RELATED ARTICLE: Follow-Up

Resources Fall Short of Needs

In UN Chronicle Issue 2, 2002 (also online at www.un.org/chronicle), we had covered issues relating to mental health. According to the latest data collected from government sources and published by WHO in Atlas: Country Profiles on Mental Health Resources, it was found that a huge gap exists between what is needed and what is available to address the massive burden of mental, neurological and behavioural disorders, estimated at 12.3 per cent of the total global disease burden.

Wealthy countries are not always rich in the quantity and quality of mental health resources. A fifth of countries do not even have the three most commonly prescribed drugs to treat disorders like depression, schizophrenia and epilepsy. The availability of mental health professionals in large areas of the world is extremely poor. More than 680 million people, the malority of whom are in Africa and Asia, have access to less than one psychiatrist per million. Many large countries, including China, Iran, Nigeria, Thailand and Thrkey, have no specific legislation for mental health, although some are in the process of developing one. Of the countries reporting, about a third spend less than I per cent of their federal health budget on mental health-related activities. Community-care facilities have yet to be developed in about half of the countries in Africa, the Eastern Mediterranean and Southeast Asia, and are not available in at least a third of other countries. About two thirds of the psychiatric beds in the w orld are in mental hospitals, although community care is considered more effective and humane. Ireland, Israel, the Netherlands and Spain have 80 to 95 per cent of these beds in mental hospitals, France, Germany and Japan 60 to 75 per cent, and Australia, Canada and the United States nearly 40 per cent.

Erika Reinhardt

Helen Herrman is Professor of Psychiatry and Public Health at the University of Melbourne, Australia and Director of Psychiatry at St. Vincent's Mental Health Service, Melbourne. From 2001 to 2002, she was acting regional adviser in mental health for the World Health Organization's Western Pacific Region.