Rapid Responses to:

EDITORIALS: Graham Thornicroft and Samantha Maingay The global response to mental illness BMJ 2002; 325: 608-609 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

WHO's ATLAS Website

Shekhar Saxena, Pallab K. Maulik, Benedetto Saraceno   (20 September 2002)

New Oppurtunities for developing countries

R.SRINIVASA MURTHY MURTHY   (23 September 2002)

First line care and mental health in low income countries

Monique Van Dormael, Jean-Pierre Unger   (27 September 2002)

WHO's ATLAS Website 20 September 2002
Shekhar Saxena, Coordinator, Mental Health: Research and Evidence World Health Organization, CH 1211, Geneva, Switzerland, Pallab K. Maulik, Benedetto Saraceno Send response to journal: Re: WHO's ATLAS Website	As the developers of WHO's ATLAS Reports, we wish to inform the readers of BMJ that the complete ATLAS database is available on the following website. http://mh-atlas.ic.gc.ca/ This interactive site allows search of data for any of the mental health resource variables for any country, WHO region or the whole world. It also allows construction of maps, charts or tables and downloading these for further use. There are links to other WHO material. We welcome comments, suggestions and updates on the database; these can be sent directly from the "Comments" button on the website.
New Oppurtunities for developing countries 23 September 2002
R.SRINIVASA MURTHY MURTHY, Professor of Psychiatry BANGALORE-INDIA 560029 Send response to journal: Re: New Oppurtunities for developing countries	The global situation about mental health resources raises two issues. There is definite crisis in terms of the extremely low priority and the limited resources for mental health care in most of the developing countries. However, the focus given to mental health by the World Health Organisation offers a new oppurtunity for the developing countries to organise mental health utilising the current knowledge about mental disorders. I specifically refers to the following advantages that exist in the developing countries. These are: (i) Majority of the ill persons are living in the community and most of them are cared for by the family members;(ii) Families continue to feel directly responsible to care and support which is an advantage in organising services;(iii) the lack of an extensive mental health infrastructure(specialists, specialist beds, different professionals etc) meanss that services can be organised utilising the community resources like, the primary health care personnel, school teachers, volunteers etc to provide mental health care- in a way there a blank canvas to organise and plan mental health services; (iv) patients living in the community has resulted in greater acceptance of the patients by the community and allows for community involvement in mental health care. Let me illustrate some of these advantages and how some countries are using this oppurtunity. Almost all of the developing countries are moving towards organising mental health care with primary health care, with focussed training programmes. Two big countries that have taken up this are India and Iran.In Iran over 60% of the rural population has been covered by integrating mental health with primary health care. In India, the initiatives begun in 1975 led to the development of a district mental health model(covering 1-2 million population).This model has now been implimented in 25 districts and expected to be extended to 100 districts in the next 5 years( over 150 million population).In SriLanka, the number of psychiatrists is around 30 for 20 million population. Last year the country trained 30 young doctors for three months and posted them to work in the peripheral health centres- nearly doubling the mental health manpower in one year.In addition, the country has increased the amount of training in psychiatry for the undergraduates(two full months) and made psychiatry an examination subject at the final year examination. The family movement is taking shape in developing countries. Contrary to the developments in the developed countries, this movement is fostering partnership between professionals and families. The massive disasters like the Orissa Supercyclone, the earthquake in Gujarat and the Riots in Gujarat have led to the development of a community based psychosocial carewith comunnity volunteers with significant benefit to the population. Even the ERWADY tragedy, last year, where 28 persons died in a fire has resulted in (i) a survey of the whole district(population 1.3 million);(ii)a community based programme with focus on mental health care at primary health care,(iii) development of vocational training centres with parents as the stake holders; (iv) developing norms for mental health care facilities and(v) massive public education. Similar developments are occurring in many countries of Asia, Africa and South America. It is well to recognise that there are special challenges for the mental health care development in developing countries. There are (i) the need for mental health professionals to shift from a clinical focus to public health focus; (ii) development of training materials, case records, information systems, treatment guidelines that are suitable to local realities; (iii) periodic evaluation of the many innovations (iv) support programmes that will meet the needs of the families (v) legislation that will protect the rights of the mentally ill as well do not limit accesss to mental health care and (vi) availability of adequate number of mental health professionals to support , supervise and guide the above innovative initiatives. The continuos brain drain of professionals from developing countries to developed co8untries is a real challenge. Many programmes of significance have not been taken to a larger scale for this reason. In conclusion, the global situation provides a challenge to professionals to think in innovative manner as well as take up the oppurtunity to organise mental health care in new ways. (Author will be glad to provide references to the above and related initiatives in developing countries to those interested).
First line care and mental health in low income countries 27 September 2002
Monique Van Dormael, Lecturer Institute of Tropical Medicine, Public Health Department, Nationalestraat 155, 3000 Antwerp, Belgium, Jean-Pierre Unger Send response to journal: Re: First line care and mental health in low income countries	Thornicroft and Maingay (1) highlight the inadequacy of international responses to mental illness. Field experience in low income countries confirms the burden of mental illness, amplified by financial insecurity, poverty, partition of families, if not by violence and war. In those countries where the bulk of the population survives under painful socio- economic conditions, prevention in mental health is intimately linked with overall human development. Individual care is also necessary. In some societies, religious or traditional healers still provide culturally relevant and socially acceptable responses to problems labelled as mental illness. Nevertheless mental suffering is manifest among users of modern medical services, where it goes largely unrecognised. Why is it so ? Besides poor availability of drugs, the “human resources” component is of utmost importance to understand the apparent neglect of mental health problems. Doctors and nurses in low income countries are often described as rude in their encounters with patients (2). Part of the problem is that many care providers live with low wages and poor professional perspectives, affecting their morale, self confidence and dedication (3). Some of them experience themselves personal problems similar to those of their patients – such as domestic violence, or living with HIV. Listening to patients’ suffering entails an emotional burden which care providers are not prepared to face: adequate professional support is unusual, and dealing with emotions is seldom valued by the organisational culture. Besides, the biomedical orientation of doctors’ and nurses’ training disqualifies listening to patients and their suffering experience and lacks culture-sensitivity (4). If health care in low income countries is to be oriented towards more “bio-psycho-social” approaches, efforts have to include the strengthening of first line care facilities and the support to first line care providers. Well functioning first line facilities are crucial to integrate mental health programmes accessible to the population. This does not rule out specialised services, necessary for referrals and technical backup and support of primary care providers. However specialised services tend to remain concentrated in cities and are often of limited financial accessibility. In the case of mental health services, stigmatisation furthermore limits their acceptability for potential users. The integration of mental health programmes in first line care facilities should of course not be detrimental to the comprehensive character of the service delivered. The purpose is not to divert available resources to serve a specific programme - in this case mental health - but rather to take advantage of the existing relations between a service and a community to widen the scope of responses provided to local health needs. At a time where health care in low income countries is increasingly thought of as a series of vertical programmes, it is essential to stress the need for access to regular health care, and to ensure that specific programmes strengthen general services rather than weakening them (5). As a matter of fact mental health programmes may contribute, under favourable conditions, to improve first line care: concerns for mental health are likely to promote listening skills, to foster patient centred care, and to broaden the professional identities of care providers, presently narrowed down to biomedical issues. This could be an important step on the way to quality general practice adapted to the social and cultural context. (6). Reference List 1. Thornicroft G,.Maingay S. The global response to mental illness. BMJ 2002;325:608-9. 2. Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Soc.Sci.Med. 1998;47:1781-95. 3. Segall M. Human development challenges in health care reform. Studies in Health Services Organisation and Policy 2000;16:7-17. 4. Van Balen H,.Van Dormael M. Health service professionals and users. International Social Science Journal 1999;313-26. 5. Declaration on "Health Care for All". 2001. Antwerp, Belgium. 6. Unger J-P, Van Dormael M, Criel B, Van der Vennet J, De Munck P. A plea for an initiative to strengthen family medicine in public health care services of developing countries. International Journal of Health Services 2002;32:799-815.