No health without mental health
Dr N.N. Wig
HEALTH, as defined in the WHO's constitution, is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It is unfortunate that people, when they talk of health, usually refer to it in physical terms only.

G.H. Brundtland speaks on mind
ON 7 April 2001, all peoples and governments around the world will observe World Health Day. This year is devoted to mental health. We focus on mental health in recognition of the burden that mental and brain disorders pose on people and families affected by them, and with the aim to highlight the important advances made by researchers and clinicians in reducing suffering and the accompanying disability.

A Nobel laureate says...
Mental illness is one of the major afflictions of mankind that has had little support in the past. During the last half century there has been quite a revolution in the understanding and treatment of major mental illness such as depression, schizophrenia, manic depression and anxiety.

HEALTH BULLETIN
Psychotherapy in the Indian context
Dr Ajit Awasthi
"Psychotherapy is the treatment by psychological means of problems of an emotional nature in which a trained person deliberately establishes a professional relationship with the patient with the object (1) of moving, modifying or retarding the existing symptoms, (2) of ‘mediating’ disturbed patterns of behaviour and (3) of promoting positive personality growth and development.

Q&A
Q Are mental and brain disorders just a figment of one's imagination? Or are they real illnesses that cause suffering and disability?

No health without mental health
Dr N.N. Wig

HEALTH, as defined in the WHO's constitution, is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It is unfortunate that people, when they talk of health, usually refer to it in physical terms only. The Sanskrit word, "swastha" expresses it more elegantly as "one who is collected in self, calm, composed, healthy, at ease etc". The Urdu word "sehat" has a similar root in Arabic — "sehat", meaning "correct, exact, balanced etc."

I sometimes ask people to make a list of priorities in their life or a list of what they want to achieve. The answers usually come in terms of a good job or a house or travel abroad. Nobody mentions "mental health" in his or her list of priorities. Then I point out to them that all of what they have listed is ultimately dependent on one thing —, their good mental health!

If one has lost one's mental health — the capacity to work, to love, to enjoy, to think clearly — , all the material things one has acquired are worth nothing and will bring no happiness. It is surprising, in spite of such obvious importance of mental health, how little thought we normally give to mental health in our day-to-day life. Worse still is our attitude towards those who suffer from mental ill health. If someone has a physical illness like heart disease or the fracture of a bone, we rush to express our sympathy but if one has a mental illness like depression or anxiety, we tend to avoid one's company and often ridicule the symptoms denoting one's suffering. It is time we re-examined our attitudes towards mental health and illness.

December 7, 2001, is perhaps a good occasion to think of various aspects of mental health. April 7 is officially World Health Day observed by all countries. This year, the World Health Organisation (WHO) has declared that it has been devoted to mental health. This is the first time in the history of the WHO that so much attention is being focused on mental health. The reason is the growing evidence about the importance of mental health in health programmes all over the world.

Mental illnesses, including neuropsychiatrict disorders, now constitute one of the biggest causes of the total burden of disease in society. Almost every family has seen the suffering of some of its members due to psychological or emotional symptoms at various stages in life.

The economic loss to the nation and the personal suffering of the individuals and families are enormous. The sad part is that though good methods of treatment to reduce the suffering now exist, the majority of patients remain untreated and uncared for.

The biggest barrier to the provision of proper services for the mentally ill is, of course, the old prejudice against mental disorders which exists as much in the medical profession as it exists in the mind of the lay public.

The health burden of mental disorders: With the dramatic increase in life expectancy in recent years, the health dynamics has undergone major changes.

Communicable diseases are being rapidly replaced by non-communicable diseases as major causes of death and disability. For too long, health professionals have been preoccupied with mortality statistics which tells us only how people die. It is equally important to know how people live and how the total burden of disease, both of death and disability, is shared by society.

During the past 10 years, a new measure "Disability Adjusted Life Year" or "DALY' has been evolved with the support of the World Bank, the World Health Organisation and Harvard Medical School. DALYquantifies not only the number of deaths but also the impact of premature death and disability on a population combining them into a single unit of measurement of the overall burden of disease.

With this shift in perspective, some of the major killers, such as cardiovascular diseases and tuberculosis, still remain prominent but mental illness suddenly bulks very large indeed. It may not in itself be fatal but it causes extensive disability in rich and poor countries alike, and is increasing! For example, mental disorders (9.7 per cent) rank almost as high as cardiovascular diseases (10.5 per cent) in the total burden of diseases. (World Health Report - 1999). The global burden of disease study thus reveals the true magnitude of the long under-estimated impact of mental health problems.

The future projections of global DALYs in the year 2020 show even a greater impact of non-communicable diseases and mental disorders. Mental disorders are projected to increase to 15 per cent of the global disease burden and depression could become the second leading cause in the disease burden after ischaemic heart disease. The Global Burden of Disease Study has, therefore, been an eye-opener (and a mind-opener) for public health.

Newer developments in neurosciences: The last two decades have seen some very exciting developments in the field of neurosciences. The human Genome map has been meticulously worked out and it is becoming clearer how multiple genes, acting together along with environmental factors, are responsible for many of the well-known mental disorders. The modern brain-imaging can now show how changes occur in different parts of the brain in response to our thinking, feeling and behaviour and how certain neural circuits fail to function in different disease conditions. Our knowledge of the role of neurotransmitters in health and disease has enormously increased.

Psychopharmacology is one of the most rapidly growing areas in pharmacology and we have in the market, almost every year, a large number of anti-anxiety, anti-depressant, anti-psychotic and anti-epileptic drugs. With these developments many people are now arguing that mental disorders are disorders of the brain and for all practical purposes these illnesses should not be viewed differently from other medical illnesses like diabetes and hypertension.

There are now many well-proven interventions available for treating mental disorders. Good and cost-effective drug treatments are available for various kinds of depressive disorders, psychotic disorders (including schizophrenia), anxiety and panic disorders, obsessive and phobic disorders, alcohol and drug dependence and so on. Psychological treatments like cognitive behavioural techniques and interpersonal therapy are effective in many more conditions. In fact, treatments for most of the mental disorders are now better studied and more efficacious than those for many other chronic human ailments. The sad part is that in spite of all these advances, most of the efficacious treatments that exist are still not available in many parts of the world. Furthermore, for most of the patients there is a long delay between the onset of mental illness and the availability of effective treatment, especially in developing countries.

G.H. Brundtland speaks on mind

ON 7 April 2001, all peoples and governments around the world will observe World Health Day. This year is devoted to mental health. We focus on mental health in recognition of the burden that mental and brain disorders pose on people and families affected by them, and with the aim to highlight the important advances made by researchers and clinicians in reducing suffering and the accompanying disability. Our message is one of concern and hope.

The road ahead is long. It is littered with myths, secrecy and shame. Rare is the family that will be free from an encounter with mental disorders or will not need assistance and care over a difficult period. Yet, we feign ignorance or actively ignore this fact. This may be because we do not have sufficient data to begin addressing the problem. In other words, we do not know how many people are not getting the help they need — help that is available, help that can be obtained at no great cost. And, because we lack this knowledge, we have not done well to address mental and brain disorders. As we fail to acknowledge this reality, we perpetuate a vicious cycle of ignorance, suffering, destitution and even death. We have the capacity - within us - to tackle the next frontier. Within people, within societies, within governments. Together we have to work to make the change.

An estimated 400 million people alive today suffer from mental or neurological disorders or from psychosocial problems such as those related to alcohol and drug abuse. Many of them suffer silently. Many of them suffer alone. Beyond the suffering and beyond the absence of care lie the frontiers of stigma, shame, exclusion and, more often than we care to know, death.

The simple truth is that we have the means to treat many disorders. We have the means and the scientific knowledge to help people with their suffering. Governments have been remiss in that they have not provided adequate means of treatment to their people. And people have continued to discriminate against those that suffer from these disorders. Human rights violations in mental hospitals, insufficient provision of community mental health services, unfair insurance schemes and discriminatory hiring practices are only some of the examples. By accident or by design, we are all responsible for this situation today.

The time for reckoning is now. Let us look at this day as an opportunity and a challenge. A day to reflect upon what remains to be done and how we can do it. Let us use this day and the weeks ahead to take stock and advocate for policy changes on the one hand and attitude changes on the other. Together with our Member States, let us pledge to work towards a day when good health will also mean good mental health.

This past century has seen spectacular changes in the way we live and think. Human brilliance and technology have come together to propose solutions we dared not imagine fifty years ago. We have conquered diseases that once seemed insurmountable. We have saved millions of people from premature death and disability. And our search for better solutions to health is, as it should be, ceaseless. The solutions to mental health problems are not difficult to find; many of them are already with us. What we need is to focus on this as a basic necessity. We must include solutions and care for mental health in our search for a better life for all in a systematic way. Only then will our successes be more meaningful. On this day, we must commit to "stop exclusion - dare to care."

A Nobel laureate says...

Mental illness is one of the major afflictions of mankind that has had little support in the past. During the last half century there has been quite a revolution in the understanding and treatment of major mental illness such as depression, schizophrenia, manic depression and anxiety. Rather than a flaw in character or a consequence of a dysfunctional family, recent research has shown that mental illness has biological roots.

—Julius Axelrod, 1970 Nobel Prize-winner for Medicine, in a letter to WHO Director-General on June 30, 2000.

HEALTH BULLETIN
Psychotherapy in the Indian context
Dr Ajit Awasthi

"Psychotherapy is the treatment by psychological means of problems of an emotional nature in which a trained person deliberately establishes a professional relationship with the patient with the object (1) of moving, modifying or retarding the existing symptoms, (2) of ‘mediating’ disturbed patterns of behaviour and (3) of promoting positive personality growth and development.

"This is perhaps the most widely accepted definition of psychotherapy given by Wolberg in 1967."

Do all people define psychotherapy in the same way or are there important differences? This question is highly relevant to the practice of psychotherapy in India.

Mental health is an integral component of health through which a person realises his or her own cognitive, affective and relational abilities. With a balanced mental disposition, one is more effective in coping with the stresses of life, can work productively and fruitfully, and is better able to make a positive contribution to his or her community. Mental and brain disorders, by affecting mental health, impede or diminish the possibility to reach all or part of the above. Preventing and treating them clears the road to achieving one's full potential.

As mental health is a fundamental building block for human development, we must face the facts that mental health problems are a part of life, that they can arise and that they can be addressed.

There is no justification in ethics, science of society to exclude persons with a mental illness or a brain disorder from our communities. There is room for everyone.

The health care system can lead the way. No rationale exists for excluding mental health services from the general health care system. Parity between physical and mental health is vital.

Provide better care; ensure access to care, insist on equity in care. All this must be done and all this is possible if we dare to believe that mental health care is a basic health concern for all. (WHO)

Q&A

A Mental disorders are real.

Mental illness and brain disorders provoke suffering, cause disability and can even shorten life as we see from episodes of depression after a heart attack, numbers of liver disease resulting from alcohol dependence or cases of suicide. The existence of mental and brain disorders often remains hidden, voluntarily by the patient or simply unrecognised as a real illness by the person and their family. Yet the underlying abnormal substructure of many disorders has been identified by images of the brain. Thus to ignore their existence is akin to denying that cancer exists because we are unable to see the abnormal cells without a microscope. Mental illnesses can be diagnosed and treated before it is too late.

"Pull yourself up — it's all in your imagination."How often have we heard that? It's not just friends and family that fail to grasp the existence of a mental disorder. Even governments choose ignorance, as seen by the fact that mental health is often excluded from their health priorities and plans.

A There are people who suffer from overwhelming fears that are accompanied by a host of recognisable symptoms. Others grapple with constant negative or unpleasant thoughts and turn to alcohol to escape. In some cases, the patient's pain can be so excruciating that suicide is seen as a relief. In the year 2000, there will have been an estimated one suicide death every 40 seconds.

It is easy to ignore or dismiss many symptoms, yet the fact is that five out of the ten most disabling disorders are psychiatric in nature Unipolar depression, alcohol use, bipolar affective disorder (manic-depression), schizophrenia and obsessive-compulsive disorder are among the 10 leading causes of disability world-wide. The disability associated with mental or brain disorders stops people from working and engaging in other creative activities, e.g., a mother may cease caring for a baby, an adolescent may stop socialising with peers, and an elderly person may no longer take care of himself or herself.

If someone has a broken arm, you feel sorry for them. But when (the problem is) psychiatric, people don't know how to react because they can't see anything. But just because you can't see someone's pain, it doesn't mean they don't need you care and support.

A Individuals react differently to stressful situations. Loss of a loved one can potentially lead to a depression. Loss of work is associated with heavy alcohol use, suicide and depression. Poor nurturing environments, whether they are the result of broken families or violence in the home or community, can result in an increased risk of mental illness.

In some places of the world, mental illnesses are thought to be caused by evil spirits. This is a difficult issue. It pits faith against fact, faith healers against doctors, cultural beliefs against scientific knowledge. Perhaps to prevent a situation from taking a turn for the worse, mental health professionals can work with healers so that those who cannot be helped by traditional medicine can receive conventional treatments. Mental health professionals serve the community better by understanding the cultural and social context within which their work is to be carried out.