Up to one fifth of the world's children have mental or behavioural problems. (Health Watch).

An estimated 10 to 20 per cent of children worldwide have one or more mental or behavioural problems. Many disorders commonly found among adults, such as depression, can begin during childhood, the World Health Organization (WHO) reports. Categories specific to childhood and adolescence include disorders of pscyhological development, including dyslexia and autism, as well as behavioural and emotional disorders, such as attention deficit/hyperactivity and conduct disorders. Their treatment requires a continuum of care over time linking settings such as families, schools, hospitals and out-patient facilities.

This grim assessment comes even as the World Health Report 2001, Mental Health: New Understanding, New Hope, published by WHO, says that as many as 450 million people worldwide suffer from mental and neurological disorders. The Report invites Governments to seek solutions that have become affordable and to foster positive changes in the acceptance of such disorders.

Depression, also known as unipolar mood disorder, for instance, is a common mental illness characterized by sadness, loss of interest in activities, decreased energy and recurring feelings of despair. The intensity and frequency of the symptoms differentiate the illness from normal mood swings. Currently, 121 million people suffer from depression. Every year, one million people commit suicide, 60 per cent of which are the outcome of depressive disorders and schizophrenia. The causes of depression vary from psychosocial factors to genetics, and its first-line treatment involves antidepressant medications and psychotherapy.

Despite the pervasiveness of psychiatric disorders, the Report affirms, nearly two thirds of people with such illness do not seek help from mental health care professionals because of the stigma and discrimination attached to the disorders. Often, untreated mental illness is the result of downright neglect. "Mental illness is not a personal failure", said Dr. Gro Harlem Brundtland, Director-General of WHO. "In fact, if there is failure, it is to be found in the way we have responded to people with mental and brain disorder."

According to the Report, it is the lack of urgency, misinformation and competing demands that prevent policy makers from recognizing that mental and neurological disorders have become the leading causes of illness and disability worldwide, affecting one in every four persons.

Depression is already the fourth cause of the global disease burden, and by 2020 it is expected to rank second following ischaemic heart disease.

The effectiveness of the response to mental health problems however does not match their magnitude, points out the Report. "Project Atlas', a new WHO project seeking to locate mental health resources around the world, found that of all the countries studied, 4] per cent are without any mental health policy. Some 25 per cent have no legislation on mental health and 28 per cent have no separate budget for it; 41 per cent lack treatment facilities for severe psychiatric disorders in primary health care and 37 per cent have no community care facilities.

While a small range of medications is sufficient to treat the symptoms of the majority of mental disorders, the Report says, about 25 per cent of countries do not have the three most commonly prescribed medications for schizophrenia, depression and epilepsy at the level of primary health care. In more than half the countries around the globe, there is only one psychiatrist per 100,000 people, and 40 per cent of countries have less than one hospital bed per 10,000 people set aside for mental illness.

People with limited financial resources are faced with the greater burden of psychiatric disorders, the Report emphasizes. Exposure to stressful events, dangerous living conditions, exploitation and poor health make them more vulnerable to develop such disorders. Poor people also experience a lack of access to proper treatment, which makes the course of illness even more devastating. Some disorders like mental retardation can be often prevented. Furthermore, despite the chronic nature of psychiatric disorders, proper care and treatment can help those with such illness lead a normal life. Up to 60 per cent of people with depression can recover with a proper combination of antidepressant medication and psychotherapy. More than 80 per cent affected by schizophrenia can avoid relapses after a twelve-month treatment with antipsychotic medication and family assistance. Low-cost anticonvulsants can prevent seizures for up to 70 per cent of people with epilepsy.

The recommendations of the World Health Report 2001 predominantly focuses on the importance of integrating mental health with primary health care. Treatment in primary care can increase the possibility for early diagnosis and reduce unnecessary examination and non-specific treatment accordingly. To do that, it is critical that general health personnel in primary care be trained in the essential skills of mental health care.

The Report also emphasizes the importance of making the shift from institutional to community care in mental health treatment. Large mental institutions or hospitals are no longer the best choice for people with such illness because they can lead to a loss of social skills, human rights violations and less likelihood of successful rehabilitation. Community care can provide better treatment and quality of life for individuals suffering from chronic mental disorders. It is also cost-effective and tends to minimize the stigma of receiving treatment. This shift requires health workers and rehabilitation services to be available at the community level. As large custodial mental hospitals are being replaced by community care facilities, general hospitals must maintain psychiatric beds and home care.

The Report argues that medications should also be made available throughout the health care system. Medicines for the treatment of psychiatric disorders and epilepsy fall into four categories: antidepressants for depression; antipsychotics for psychotic symptoms; anti-epileptics for epilepsy; and anxiolytics--tranquillizers--for anxiety.

These psychotropic medications are the first line of treatment, especially in the absence of psychosocial interventions and highly skilled professionals. In addition, many older brand medications are reaching the end of their patent protection, giving developing countries access to cheaper generic brands. Thus, they must be included in every country's essential list of medicines.

Other recommendations in the Report are: public education and awareness campaigns to reduce stigma and increase care; involvement of communities, families and consumers in the development and decision-making of mental health policies; and establishment of national policies, programmes and legislation. Most developing countries need to increase their budgets for mental health, the development of human resources and cooperation with other sectors. The work of other sectors, such as education, labour, welfare and law, has tremendous influence on the quality of life of people with mental illness. Monitoring of community mental health and support for more research into biological and psychosocial aspects of mental disorders are also necessary.

The Report emphasizes that with courage and commitment, every country, no matter what its resource constraints may be, can improve its people's mental health by choosing from among a large number of services and a wide range of prevention and promotion strategies. "Science, ethics and experience point to clear paths to follow", said Dr. Benedetto Saraceno, Director of the WHO Mental Health and Substance Dependence Department. "In the face of this knowledge, a failure to act will reflect a lack of commitment to address mental health problems."

Dr. Brundtland added that she hoped the Report would "dispel long-held doubts and dogma and mark the beginning of a new public health era in the field of mental health".

More information regarding World Health Report 2001 can be obtained at <http://www.who.int/whr>.

The Circle of Care


Community       Avoidance of stigma and discrimination
                Full social participation
                Human rights

Family          Skills for care
                Family cohesion
                Networking with families
                Crisis support
                Financial support
                Respite care

Rehabilitation  Social support
                Education
                Vocational support
                Day care
                Long-term care
                Spiritual needs

Medical         Early recognition
                Information about illness and treatment
                Medical care
                Psychological support
                Hospitalization

Source: World Health Report 2001

RELATED ARTICLE: As many as 20 per cent of children worldwide are suffering from behavioural or mental problems, which could lead to serious public health problems, according to UNICEF and WHO. The UN agencies blame the trend on rapid social and economic changes, as well as on poverty and conflicts. Teenagers are especially of concern, since they are more likely to suffer from serious health problems than younger children, yet are neglected by health officials. WHO reported that 70 per cent of premature adult deaths can be linked to negative adolescent behaviour, such as smoking and substance abuse. Hans Troedsson, WHO Director for child and adolescent health, stated that without the right action, millions of children growing up will suffer from the effects. The United Nations calls for ways to improve adolescent health as part of this decade's agenda for global child survival.