Of mental health, science and human rights

Published : Mar 12, 2004 00:00 IST

V. SRIDHAR

V. SRIDHAR

Interview with Dr. Benedetto Saraceno, Director, Department of Mental Health, WHO.

Dr. Benedetto Saraceno, Director of the Department of Mental Health in the World Health Organisation (WHO), is an acclaimed Italian psychiatrist. He was among the psychiatrists who initiated a reform movement in Italy in the 1970s that resulted in a dramatic shift in the way practitioners of mental medicine treated their patients. It also led to the enactment of a law that stopped mental patients from being treated in large psychiatric institutions and provided for their treatment in psychiatric wards in general hospitals, resulting in the removal of the stigma that is associated with mental illnesses. Dr. Saraceno points out that there are no psychiatric hospitals in Italy.

According to him respect for the human rights of patients and their right to "full enjoyment of citizenship" is the key to any credible effort by the medical profession to address mental health issues. He believes that there is greater awareness of the growing burden of mental illness, thanks to the involvement of non-governmental organisations and other sections of civil society.

Politicians, he says, now appreciate that mental illnesses need to be placed on national health agendas and that they are as important as dealing with infectious and communicable diseases. However, he warns that volunteerism can be an excuse for the state to withdraw from its role as a provider of health care. This, he says, is a real threat in a situation in which states are increasingly under pressure to adopt a market-oriented approach to health care. Recently in Chennai to participate in an international conference on schizophrenia, Dr. Saraceno spoke to V. Sridhar. Excerpts from the interview:

What is the extent of the problem of mental health in general and suicides in particular at the international level? How serious has it become in the last decade?

We can look at the problem of mental disorders from two different angles. The simple way is to look at it in terms of numbers, that 450 million people in the world are suffering from mental disorders. The risk of looking at the problem in purely statistical terms is that it would miss the implications of the problem in all its dimensions.

A more sophisticated and intelligent way of looking at the problem is to use the notion of DALYS - Disability Adjusted Life Years - a measure that combines the premature mortality due to a disorder with the disabilities that are a result of that disorder. People die due to diseases but they also suffer disability because of the diseases. If we look at mental disorders from the perspective of the burden they represent in terms of years of disability they cause, it will change our perception of mental disorders. The burden of mental disorders is more than 12 per cent of the global burden of all diseases. We expect this to increase to 15 per cent in 2020. Depression ranks fourth among all disabilities; it will rank second in 2020.

Mental disorders not only cause suffering but they prevent people from being productive. The public health alarm of mental disorders represents one of the major burdens for communities and nations. No development is possible without mental health. The most important cause of mandays lost due to illnesses in the industrialised countries is depression. The lack of recognition of the problem can have adverse consequences for the economies of nations in the world.

The problem of mental health is huge. Worldwide, about 140 million people suffer from depression; 24 million people suffer from schizophrenia; and, every year 20 million people attempt suicide, of which one million actually kill themselves. Beyond these figures, alcohol creates problems not only for the drinkers themselves but also has implications for domestic violence, depression among women, which in turn, leads to mental health problems for children.

What are governments doing to tackle this huge problem?

The paradox is that although the burden of mental disorders is huge, and treatments for these are available and are relatively cheap, the problem continues to mount. The cost of treating epilepsy is about $12 per patient annually but about 30 million people suffer from epilepsy. The cost of treating people with mental disorders is not terribly expensive. A combination of relatively cheap medicines and family support can effectively handle the problem. If the burden is huge and cost-effective treatment is available, why is the gap so huge? Ninety per cent of people suffering from epilepsy in Africa are not receiving any treatment. Well, one can say Africa is a poor continent. But even in the U.S. less than 25 per cent of people with depression are receiving proper treatment. The gap between the treated and untreated, between those reached and those not reached, is enormous.

This gap exists because there are barriers to the implementation of the available knowledge in the field of mental health. The first barrier is stigma and the discrimination attached to those suffering from mental disorders. This prevents those affected from being properly treated because the family hides the patient from the health services. This means that the patient remains hidden. People imagine that this happens only in developing countries. It is not so. Imagine that a senior officer like me is suffering from depression, which requires that I take one month of medication and rest from my job. If this happens, it will affect my image and even my career. So, in a way, I am stigmatised. Nobody would regard my disorder like any other.

The second barrier is the wrong public health choice in the matter of allocating money for mental health. In many countries, 80-90 per cent of the financial resources go to maintain large, ancient, inhuman and outdated mental health institutions. There was the episode in India (Ervadi) of an institution which was supposedly taking care of mentally ill patients but basic human rights were violated. Money is being allocated to such institutions even when we know that the most effective interventions are community-based ones. Sometimes, this also explains why people do not seek treatment. If the only option is a psychiatric hospital, very far from the village and one that is terribly maintained, people will turn to strange healing systems.

The third barrier is that we do not have enough specialists to deal with the problems of mental illness. There is also a need to mainstream the skills and knowledge of mental disorders, particularly in recognising and treating them. This means training primary health care doctors, nurses and social workers. We need the knowledge at that level because they are the people who are working in the community. We must use the few psychiatrists as multipliers so that mental illnesses are treated effectively in the communities.

The fourth barrier is the discrimination against the mentally ill. This can have terrible consequences for non-treatment of mental illnesses. An example from the industrialised countries will illustrate this. Insurance schemes are not recognising the parity between physical and mental illnesses. Insurance companies reimburse expenses on physical ailments but not mental ailments. This practice is pervasive in many countries.

Simply put, the sad story of mental health is as follows: The problem is huge, although solutions are available at very little cost. The barriers to the implementation of these solutions are also high. We need more awareness among politicians and policymakers that investing in mental health is better than non-treatment. Non-treatment is much costlier than treatment because the consequences of non-treatment are huge.

WHO is already overwhelmed by a variety of health problems, particularly in developing countries. Diseases such as TB, HIV/AIDS, and malaria are already on the agenda. When does the issue of mental health figure in WHO's list of priorities?

It's a myth that non-communicable diseases are less relevant than communicable diseases. WHO is committed to addressing both sets of problems with the same level of attention. Take the case of HIV/AIDS, for instance. Look at the mental health implications behind the disease itself. Moreover, drug-dependence, via injections, is a major source of infection of HIV/AIDS. Unsafe sexual behaviour in youngsters is also linked to problems such as alcoholism, and therefore to mental health. We also have evidence that depression can cause non-adherence to drugs and drug dosages for treating diseases like TB, diabetes or hypertension. We have also noticed links between depression and heart attacks. Mental illnesses such as schizophrenia, depression, Alzheimer's disease and dementia are all major issues in global terms.

The process of globalisation has accelerated in the last decade. Societies in transition have experienced trauma, as a result. The tremendous churn that the world has gone through in the last decade has meant that families are less stable, jobs and incomes are less stable, and life is generally perceived to be less stable. What has been the impact of globalisation and market-based approach in the area of mental health?

From a scientific perspective, it is not easy to link the phenomenon of globalisation to the problem of mental health. We should have a well-structured definition of globalisation. Otherwise, we run the risk of using these concepts in a meaningless way. My view would be to keep a high level of science in understanding the problem. We know that job losses, not merely unemployment, are the contributory factor in suicidal behaviour. It's the effect of the job loss, resulting in frustration and desperation, which causes this. A superficial way of looking at the problem would be to claim that poverty is what causes suicides. I would say that "neo-poverty", which happens because of the sudden disruption of families, societies and communities, is a better explanation as a contributory factor. Conflicts and wars have increased - there are about 50 million refugees - and this has also exposed people to stress.

In the last three years there has been greater awareness about mental health. That is the good news. But there is also bad news. The good news is that mental health figures more prominently in the public health agenda. The efforts of WHO and also of many people across the world have convinced politicians and policymakers that the global burden of disease is highly influenced by the toll of neuropsychiatric disorders.

I think politicians have understood the magnitude of the problem. Moreover, politicians and policymakers in developing countries now understand that tackling only infectious diseases, following the traditional public health assumptions that only the poor suffer from infectious diseases and that the problem of non-communicable diseases is confined only to the rich, is an over-simplification.

There are many countries that are neither very rich nor very poor. They are experiencing the so-called epidemiological transition. They have all the diseases that go with poverty (diarrhoea for instance) but they also have the diseases of the industrialised countries (diabetes, hypertension and cardiovascular diseases, cancer, mental disorders, for instance). In fact, the people of these countries - China, India, Indonesia, Brazil, Iran and others - represent the majority of the world's population. These countries are undergoing a transition. They suffer from infectious and non-infectious diseases. Politicians are now realising that not addressing mental health problems in their countries results in many problems. The cost to the family when someone is mentally ill is also huge. Politicians realise that addressing mental health disorders is not simply a matter of addressing strange and bizarre disorders of people who are locked up in strange and bizarre places. Globally, one out of every four families has a person affected by a mental health problem.

Things are a little bit clearer in the political agenda. That is the good news. The bad news is that there still remains a lack of resources and skills at the primary health care level in poor countries. In India, for instance, there are not enough specialists at the primary level to address mental health disorders. We need more doctors at that level. Many countries need adequate supplies of psychotropic drugs. So, the bad news is that despite growing advocacy, awareness and recognition that mental health is a serious issue for communities and societies, a huge backlog of unaddressed needs remains.

You said that there is greater political awareness. Where has it come from? Has it come from the medical profession, lobbying by social activists... ?

It is a mix of all these. I would say that in the last 10 years civil society has played a more important role in creating awareness than the medical professionals. The most impressive advance in awareness about mental health disorders has come from NGOs, family associations and consumer associations. This was unthinkable 20 years ago. There are now thousands of NGOs doing things. I think communities and societies have matured in the last 20 years. The fact that there is greater awareness means that the scope for greater impact is also greater. People know better, they understand better than they did 20 years ago. But there still remain many obstacles in the path of implementing what societies are more aware about.

The first obstacle is that the discrimination against the mentally ill is still very high. The second is money. Money often goes to the wrong places. The cost of maintaining asylums for the mentally ill is huge. But the capacity of asylums to provide an appropriate response to the problem of mental health is pretty small. Countries are putting a large part of their resources in asylums although that money could be spent in better ways. However, much of the money actually needs to go to communities, which need to organise themselves so that they are equipped to address mental health disorders. So, there is an imbalance in the way money is spent.

The public perception is that a mentally ill patient is a dangerous person and is best locked up. But, paradoxically, doctors themselves strengthen this perception. They are delighted to remain in their offices instead of visiting the communities where the disease is prevalent. They find the option of staying back in their hospitals more prestigious. The pomp that goes with their office is also attractive. A senior doctor would rather be the chief psychiatrist in a large hospital. The larger the hospital, indicated by the number of beds, the greater is the prestige for the doctors working there. There is therefore a resistance from doctors to move towards the community where the problem is actually present. As a result, we tend to invest too much in hospitalisation, in acute care. But the long-term care at the community level is neglected.

In recent years the market orientation of governments across the world has adversely affected health budgets. The state is said to be stepping back from its traditional role as a provider of health services. How has this affected the treatment of mental health disorders?

Mental disorders are a mix of biological (or medical) and social issues. Privatisation makes it difficult for people to access adequate and long term care. I tend to agree that privatisation and the perception of health as a commodity creates a situation in which one forgets that health is essentially a human right. These issues came to the fore when the South African and Brazilian governments raised the issue of the exorbitant cost of anti-retroviral drugs for the treatment of AIDS. This was an ethical issue. It is not a matter of cost alone. The poor are saying: "We may be poor, but we want drugs and treatment at a reasonable cost."

You talked about NGOs and volunteerism. But there is worry that leaving matters to voluntary action and spontaneity is merely paving the way for the state to withdraw even more from its duty of providing access to health care.

This is a hot issue today. There is a generally nave understanding about voluntary action. Much of this is done in the name of the community, with a lot of goodwill... in much the same spirit as boy scouts. But the point is, where is the government in all this? We need boy scouts, we need solidarity, we need the community and we need voluntary action. But all this cannot be taken to mean that the problem of access to health is a question of mere charity. Health, like education, is a basic and core governmental responsibility. Governments should back the resources and efforts of community and voluntary action. The tragedy of the so-called "compassionate capitalism" is that the state cannot perform its basic tasks. We need the state as a provider. But the state should also make intelligent use of the hidden resources available in civil society.

Can you tell us something about the reform movement led by psychiatrists in Italy?

Large mental health institutions in Italy were inhuman and where freedom for the patients was violated. The situation was such that even clinical recovery was not happening and patient's condition actually worsened. Psychiatrists of my generation reacted to this. We started a reform movement in the 1970s, which resulted in a famous legislation (Law 180) which stopped the hospitalisation of patients in large psychiatric institutions, and promoted psychiatric wards in general hospitals and community mental health centres. In ten years the mentally ill in Italy were completely removed from these large institutions. There are now no psychiatric hospitals in Italy. There are three kinds of facilities for patients suffering from acute mental health problems. There are wards in general hospitals; for severely-ill patients we have protected apartments or half-way houses, not psychiatric hospitals; and for the ambulatory patients we have community mental health centres. These three levels of care have replaced the ancient and traditional psychiatric hospitals.

My experience in the field of psychiatry has led me to hold certain strong beliefs. Human rights and the full enjoyment of citizenship are the preconditions for any serious talk on mental disabilities. You are credible talking about mental health if you are really securing the full enjoyment of citizenship. Citizenship is the key word. Being a citizen is the best treatment for mental health problems. All kinds of isolation, separation and discrimination of patients lead to a worsening of health from a mental health perspective. This is the first principle which was truly applied in the reform in Italy. Italy, the Nordic countries, Australia and Brazil were among the leading reformers in the area of mental health. The second important principle is that there is a need to increase the level of science in treating mental illnesses. There is too much of theory and opinion going around.

We need to combine the civil passion, which recognises the rights of the patients, with the intellectual passion for science. Civil passion without science will be a disaster; and science without social commitment is a disaster as well. These two ingredients need to mix to make a difference to mental health and well-being. That is the lesson I learnt in Italy and later in Latin America.

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