Implementation Of 'A Vision For Change' For Mental Health Services

The Global Burden of Disease (GBD 2010) is the most comprehensive effort to date tomeasure current levels and recent trends in all major diseases, injuries, and risk factors.8There have been changes in terminology and classification from previous GBD studies.GBD 2010 introduced a new classification of mental health disorders and two categorieshave been distinguished: neurological disorders and mental and behavioural disorders.Some of the 2002 and 2004 disorders (reported in the Table 1 above) are nowencompassed in other disorders. In particular, post-traumatic stress disorder, obsessivecompulsive disorder and panic disorder are all encompassed in anxiety disorders; whathad formerly been termed ‘mental retardation’ is now encompassed in idiopathicintellectual disability; and insomnia is encompassed in other mental and behaviouraldisorders.The following table (Table 4) shows the mean DALYs values for 2010 for the mental andbehavioural disorders.Table 4: 2010 DALYs for mental and behavioural disorders.Global Burden of Disease inAge-standardised DALYsper 100,000 by causeMental and behavioural disorders2010Mean DALYs2,682.8Schizophrenia201.8Alcohol use disorders258.8Drug use disorders287.7Unipolar depressive disorders1,087.7Bipolar affective disorder188.3Anxiety disorders390.8Eating disorders31.3Pervasive development disorders111.1Childhood behavioural disorders88.5Idiopathic intellectual disability14.9Other mental and behavioural disorders21.9Source: Institute for Health Metrics and Evaluation, University of Washington (2013)8GBD 2010 is led by the Institute for Health Metrics and Evaluation (IHME) at the University ofWashington and a consortium of several other institutions including: Harvard University, Imperial CollegeLondon, Johns Hopkins University, University of Queensland, University of Tokyo and the WHO.7

It is important to note that due to changes in the disorder classification and in the basisfor calculations, values showed in Table 4 are not comparable with values presented inTable 1.Political framework: mental health policiesDuring the recent Sixty-fifth session of the World Health Assembly held in Geneva inMay 2012, a number of public health issues were discussed and some resolutions wereadopted. Among these was resolution WHA65.4 on the global burden of mental disorderswhich asks Member States to take 5 main actions:1.2.3.4.5.According to national priorities and within their specific contexts, to develop andto strengthen comprehensive policies and strategies that address the promotion ofmental health, prevention of mental disorders, and early identification, care,support, treatment and recovery of persons with mental disorders;To include in policy and strategy development the need to promote human rights,tackle stigma, empower service users, families and communities, address povertyand homelessness, tackle major modifiable risks, and as appropriate, promotepublic awareness, create opportunities for generating income, provide housing andeducation, provide health-care services and community-based interventions,including de-institutionalised care;to develop, as appropriate, surveillance frameworks that include risk factors aswell as social determinants of health to analyse and to evaluate trends regardingmental disorders;to give appropriate priority to and to streamline mental health, including thepromotion of mental health, the prevention of mental disorders, and the provisionof care, support and treatment in programmes addressing health and development,and to allocate appropriate resources in this regard;to collaborate with the Secretariat in the development of a comprehensive mentalhealth action plan.The WHA65.4 resolution highlights once again the need for a stronger commitment tomental health and the requirement for action. However, this has previously beenrecognised by the majority of European countries, who have emphasised mental health asa priority area in recent years. The Mental Health Declaration was signed in Helsinki in2005 and governments committed to addressing the challenges in the mental healthsector. This included the implementation of a wide range of activities in a number ofareas, such as mental health promotion, mental disorder prevention, preventing stigma,service provision, human rights and the empowerment of service users, families andcarers. Internationally, most policy, planning documents and legislation have beendeveloped or updated since 2005.The WHO Mental Health Atlas Project, launched in 2001, was an attempt to map mentalhealth resources in the world. It was updated in 2005 and the 2011 version of the Atlasrepresents the latest global picture of resources dedicated to the mental health sector. Theproject involved a survey of all Member States with data being obtained from 184 of 1938

Member states, covering 95% of WHO Member States and 98% of the world’spopulation.The presence of a national policy on mental health is widely viewed as fundamental inraising awareness and securing resources, therefore developing and strengthening policyfor mental health remains a key concern. Most countries now have national or regionalmental health policies in place; the Mental Health Atlas 2011 (WHO) report indicatedthat 60% of countries have a dedicated mental health policy covering roughly 72% of theWorld’s population (Table 5).In addition to dedicated mental health policies, the majority of the countries report thatmental health is mentioned in their general health policy: the majority of Member States(54%) have both a dedicated mental health policy and specifically mention mental healthin their general health policy. Twenty three per cent of countries only include mentalhealth in their general health policy with no separate dedicated mental health policy.As recommended in the “Mental Health Policy, Plans and Programmes” (WHO, 2004),mental health plans should outline the tangible details that will allow the implementationof the policy. They should also specify other crucial elements such as the budget andtimeframe for implementing strategies and clarify the roles of different stakeholdersinvolved in the implementation of activities defined within the mental health plan.Mental Health Atlas 2011 (WHO) report indicated that a mental health plan is present inalmost three-quarters (72%) of responding Member States again with notable differencesby WHO region. Among countries with mental health plans, 82% approved or revisedtheir mental health plan in 2005 or later, while only 6% continued with plans created oradapted before 2000.Table 5 illustrates the proportion of countries with a mental health policy and theproportion of the population covered by these policies, for the world and for Europe. Ofthe countries with mental health policies, the majority have a corresponding mentalhealth implementation plan; the percentage of the population covered by theimplementation plans is also presented in Table 5.Table 5: The proportion of countries in the world and Europe with a mental health policy andimplementation plan, and the corresponding population coverage% Countries withMental HealthPOLICYWorld59.8%Population Coverage % of the Countries Population Coverage(%)with Mental Health(%)PLAN(of those with amental health policy)71.5%Europe73.1%90.8%Source: adapted from Mental Health Atlas 2011 (WHO)71.2%94.8%81.0%95.2%9

Economic aspects of mental healthAnother indicator of the priority given to mental health within the health sector is theproportion of total health expenditures directed towards mental health. In terms of overallmental health expenditure, the global median percentage of government health budgetexpenditures dedicated to mental health is 2.8% as indicated by Mental Health Atlas2011. The median percentage of health expenditures dedicated to mental health is 0.5%in low income countries and 5.1% in high income countries, with graduated values inlower- and upper-middle income countries.Mental Health Atlas 2011 (WHO) reports that the global median mental healthexpenditure per capita is US 1.63 per year ( 1.25 at the current exchange rates). Datawere obtained converting local currency figures of the interviewed Countries to USD(May 1, 2011) in order to compare mental health spending across States. Notsurprisingly, mental health expenditures per capita are more than 200 times greater inhigh income countries (USD44.84 mental health expenditures per capita; 34.5 at thecurrent exchange rates) compared with low income countries (USD0.20 mental healthexpenditures per capita; 0.15 at the current exchange rates).Despite the diversity between countries in relation to their economies, investment andstage of development of mental health reforms and policies, there is clear evidence tosuggest that all countries are supporting deinstitutionalisation, establishing services closeto where people live and integrating those with mental health problems in thecommunity.9 There has been an intense debate between those in favour of the provisionof mental health treatment and care within hospitals and those who prefer treatment andcare in community settings. Solid research has established that movement frominstitutions to community life has beneficial developmental outcomes when comparedwith that of people living in institutions.10There is a strong consensus to move towardsdeinstitutionalisation that reflects the acknowledgement of the failure of the system ofcare based on old-fashioned and remote institutions and the higher quality of serviceprovided in community-based mental health services.The findings of a study11 performed by WHO Regional Office for Europe’s HealthEvidence Network (2003) shows that there is no scientific evidence that communityservice alone can provide satisfactory comprehensive care. Nor are there persuasivearguments or data to support a hospital-only approach. The results of the study supportbalanced care which means that mental health services should be provided in communitysettings close to the population, with hospital stays arranged promptly when necessary.Modern community-based and modern hospital-based care should be working together asintegrated parts of a comprehensive mental health system, to be able, for example, to9Martin Knapp et al. (2007), Mental health policy and practice across Europe, European Observatory onHealth System and Policies Series.10European Commission (2008), Mental Health in the EU: key Facts and Figures. EU Health andConsumer Protection Directorate.11Graham Thornicroft and Michele Tansella, (2003), What are the arguments for community-based mentalhealth care? WHO Regional Office for Europe’s Health Evidence Network, Copenhagen.10

respond quickly to the need to communicate or transfer patients between differentservices. The major risk is to consider the two components as mutually exclusive and tofall into a false dichotomy between hospital and community services.12 The differentservices and interfaces among them all play an important role. Such interfaces shouldexist between the whole range of statutory, voluntary and community organisations.In three studies involving costs and outcomes (Jones et al., 1984; Knobbe et al., 1995;Stancliffe and Lakin 1998; 2005, this latter for people with intellectual disabilities), costsof community services ranged from 5% to 27% less than institutional services. While theresults of these studies support a shift towards community based mental health care,caution is needed in considering and interpreting these results. In terms of costs thesecomparisons can be misleading as institutional and community services differ in manyimportant aspects, such as the characteristics of the populations served, staff wage ratesand condition of employment and the array of services provided.The WHO Regional Office for Europe’s Health Evidence Network study (2003)mentioned above, found little difference overall between hospital and community costs,suggesting that community care is more cost-effective than long-stay hospital care due toimprove effectiveness in terms of patients outcomes rather than lower costs. It isimportant to understand the economic impact of shifting care institutions to thecommunity and the transitional period has to be carefully planned and monitored.Several economic studies (Knapp et all, 1997, 2005, 2007, McDaid et all, 2009, 2010)emphasise the importance of understanding the economic consequences ofdeinstitutionalisation as a key step for the success of the operation. These studieshighlight the fact that from a practical point of view, the first patients to be transferred areusually those with fewer clinical needs, while the patients with more complex or higherneeds and whose care costs more, remain in the hospital. Consequently, during thistransitional phase, there is a risk of transferring too much funding out of hospitals in theearly stages when low dependency patients are moving, and underfunding for the newcommunity placements in the middle- to long-term when the high-need patients will alsobe transferred.At the same time, the shift from an institution-based care towards a community-basedarrangement involves multiple life domains like housing, social services, education andemployment, especially for people with complex health problems. This implies that alsoat funding level such a shift should take place, from almost an exclusive reliance on thehealth system, to a mixed economy of services that draw resources from multiple fundingsources. The transitional phase can take several years to implement and communitybased services have to be operational before hospitals are closed. During this period thereis a need to fund both hospitals and community services. Experience shows the need forsome bridging finance or the so called “parallel” funding.13 WHO (Euro Observer, 2007)also highlights that shifting care from institutions to the community means (leads to)12Graham Thornicroft and Michele Tansella, (2004). Components of a modern mental health service: apragmatic balance of community and hospital care: overview of systematic evidence, British journal ofPsychiatry, 185:283-290.13Mental Health Policy Project Policy and Service Guidance Package, WHO, 200111

rising indirect costs sustained by caregivers, mainly families and voluntary organisations,and society as a whole.Across all countries, great challenges remain and further work is required. One of themajor problems is the substantial gap between the burden caused by mental disorders andthe resources available to prevent and treat them14. A significant amount of work stillremains in order to gather evidence to determine best practice approaches. This ishindered by the fact that data on mental health resources have not been systematicallycollected in many countries. While most countries collect mental health data on personstreated in psychiatric hospitals, general hospitals, outpatient facilities and day treatmentfacilities, fewer countries collect data from primary care facilities and communityresidential facilities. As for any other aspect of health services, accurate and timelyinformation is vital for mental health service planning, implementation and monitoring.Mental Health Services in EuropeActivity in mental health policy has flourished in recent years. Since 2005, 57% ofcountries have adopted new mental health policies in Europe. WHO Europe “Policies andpractices for mental health in Europe - meeting the challenges” (2008) is an overview ofpolicies and practices for mental health in 42 Member States in the WHO EuropeanRegion. It reports that most countries have opted for a separate mental health strategy, butmany have included mental health within their overall health policy documents. There isopen discussion on the merits of the two approaches. The advantages of an integratedstrategy include avoiding the fragmentation and isolation of the mental health sectorwhile the advantages of a separate policy are greater flexibility and visibility.International concern and effort are long overdue since at least one in four people inEurope experience a significant episode of mental illness during their lifetime15 and thereis still a high “treatment gap” between the need for and the receipt of appropriateservices. While mental health problems account for approximately 20% of the totaldisability burden of ill health across Europe (as shown in Table 2), the mental healthsector receives a lower proportion of total health expenditure, often below 5%.16 Figure 1focuses on the EU-15 countries and illustrates the mental health budget or expenditure asa proportion of the total health budget or expenditure. The most recent data available arepresented, predominantly from 2004 to 2006. Data were unavailable for Austria,Belgium, Finland, Luxemburg and Greece and were only available for certain regions ofthe UK and Spain.14Kohn et al (2003), The treatment gap in mental health care, Bulletin of WHO, 82:858-66Knapp et al. (2007), Mental Health Policy and Practice across Europe-The future direction of mentalhealth care,Open University Press, England16Mental Health Atlas 2011 (WHO)1512

Figure 1: Mental health budget or expenditure as a proportion of the total health budget orexpenditure, EU-15 countriesMental health budget or expenditure as a proportion of the totalhealth budget or alSource: Adapted from WHO Europe “Policies and practices for mental health in Europe meeting the challenges” (2008)The proportion of the health budget dedicated to mental health, ranges from 13.8% inEngland and Wales to 3% in Portugal.The report “Policies and practices for mental health in Europe” (WHO, 2008) explainsthat national budgets often underestimate total expenditure on mental health. The moreadvanced the community-based and primary care mental health services, and the moredecentral

Mental Health, Mental Health Europe NGO and the UK Royal College of Psychiatrists7. "No health without mental health" has also been adopted by the Irish organisation Mental Health Ireland, Supporting Positive Mental Health. Burden of Mental Disorders Mental disorders have been found to be common, with over a third of people worldwide