Mental health in Europe
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《英国医生杂志》
New action plan will help improve care, especially in eastern Europe
In January 2005 the Mental Health Declaration for Europe and the Mental Health Action Plan for Europe were endorsed by the ministers of health of the 52 member states in the European region of the World Health Organization at a meeting in Helsinki.1 2 An unprecedented array of organisations of service users, non-governmental organisations, and professionals had been consulted in preparing these statements, which now set a clear policy direction for the development of mental health services in the wider Europe for at least the next decade. In which direction is the new policy going and how far is it wise?
The background to these new policies is a clear divide between the countries of western Europe, which have largely completed the process of deinstitutionalisation, and the position in most central and east European states, in which the transition from institutional care to a more balanced mix of services is starting only now (figures 1 and 2 are on bmj.com).3-6 At its worst, the challenges of institutional practices (persisting from totalitarian times), very low funding, and remote locations have led to severe abuses of human rights at mental hospitals in several east European countries.7 8
The WHO declaration is quite clear that in future mental health services in Europe should no longer be in isolated and large institutions but should be provided in a wide range of community based settings. Interestingly, going beyond the location of services, the policy refers repeatedly to the need to achieve the social inclusion of people with mental illness (for example, in the labour market), and to reduce discrimination.9 It also specifically encourages the role of non-governmental organisations as the "yeast," bringing innovation into mental health care.
The Mental Health Action Plan is somewhat more specific in its content. It recommends a series of actions under five key headings—to foster awareness of mental wellbeing, to tackle stigma, to implement comprehensive mental health services, to provide a competent workforce, and to recognise the experience and importance of service users and carers in planning and developing services.
From the perspective of a service user or consumer what is the importance of these recommendations? That a consumer role is given such prominence is both overdue and welcome, although these documents are noticeably vague on such details as how funding should be provided to initiate and consolidate service user groups, at the same time as respecting their autonomy.10 Further, no attention is given here to more complex questions of how the views of children, or those who lack capacity, can be represented. Little emphasis is placed in these documents on the mental health of the younger and older segments of the European population. On the positive side, the action plan actively encourages the use of legislation about disability rights in each member state of the European WHO region on an equal basis for people with disabilities related to physical illness or to mental illness.11
But do these polices go far enough? They tread a broad but often uneasy path between advocating for mental health promotion and prevention strategies for the whole populations (the focus of the European Commission), emphasising the need to respect human rights (the domain of the Council of Europe), and targeting services towards people with established mental illnesses in proportion to their degree of disability (a prime interest of WHO). These policies therefore do not state clearly whether or not treatment and care should take precedence over promotion and prevention. Most European countries cannot afford to do both of these activities well, and in some states few mentally ill people receive any effective treatment. A recent comparative international study of depression found that none of the patients in St Petersburg received evidence based treatment in primary care, and only 3% were referred on to specialist mental health care.12 The inability of patients to afford out of pocket costs was the primary barrier to care for 75% of the depressed patients studied.
This core issue of finance is dealt with well in these documents. WHO calls on European nations to make investment in mental health an identifiable part of health expenditure to achieve parity with investment in other areas of health. This has very important implications since mental disorders contribute about 12% to the global burden of disease, whereas European countries spend on average about 5% of their health budget on mental health care.6 The lowest reported budgets, at less than 2%, are all in the countries of the former Soviet Union.6 Such parity of expenditure is therefore a necessary ingredient to redress historical neglect of mental health, both East and West, for example within European Union Research and Development budgets. WHO is to be congratulated on stating the principle of parity in funding so unequivocally.
Graham Thornicroft, professor of community psychiatry
Health Service Research Department, Institute of Psychiatry, King's College London, London SE5 8AF (g.thornicroft@iop.kcl.ac.uk)
Diana Rose, co-director
Service User Research Enterprise (SURE), Health Service Research Department, Institute of Psychiatry, King's College London, London SE5 8AF
Figures 1 and 2 are on bmj.com
Competing interests: GT attended the WHO European Ministerial Conference as a temporary adviser to the World Health Organization.
References
World Health Organization. Mental health declaration for Europe. Copenhagen: WHO, 2005.
World Health Organization. Mental health action plan for Europe. Copenhagen: WHO, 2005.
Tomov T. Central and eastern European countries. In: Thornicroft G, Tansella M, eds. The mental health matrix. A manual to improve services. Cambridge: Cambridge University Press, 2001: 216-27.
World Health Organization. Mental health in Europe. Country reports from the WHO European network on mental health. Copenhagen: WHO, 2001.
Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence. Br J Psychiatry 2004;185: 283-90.
Knapp MJ, McDaid D, Mossialos E, Thornicroft G. Mental health policy and practice across Europe. Buckingham: Open University Press, 2005.
Amnesty International. Memorandum to the Romanian government concerning inpatient psychiatric treatment. London: Amnesty International, 2004.
Mental Disability Advocacy Center. Cage beds. Budapest: Mental Disability Advocacy Centre, 2003.
Social Exclusion Unit. Mental health and social exclusion. London: Office of the Deputy Prime Minister, 2004.
Chamberlin J. User/consumer involvement in mental health service delivery. Epidemiol Psychiatr Soc 2005 (in press).
Sayce L. From psychiatric patient to citizen. Overcoming discrimination and social exclusion. Basingstoke: Palgrave, 2000.
Simon GE, Fleck M, Lucas R, Bushnell DM. Prevalence and predictors of depression treatment in an international primary care study. Am J Psychiatry 2004;161: 1626-34.
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The background to these new policies is a clear divide between the countries of western Europe, which have largely completed the process of deinstitutionalisation, and the position in most central and east European states, in which the transition from institutional care to a more balanced mix of services is starting only now (figures 1 and 2 are on bmj.com).3-6 At its worst, the challenges of institutional practices (persisting from totalitarian times), very low funding, and remote locations have led to severe abuses of human rights at mental hospitals in several east European countries.7 8
The WHO declaration is quite clear that in future mental health services in Europe should no longer be in isolated and large institutions but should be provided in a wide range of community based settings. Interestingly, going beyond the location of services, the policy refers repeatedly to the need to achieve the social inclusion of people with mental illness (for example, in the labour market), and to reduce discrimination.9 It also specifically encourages the role of non-governmental organisations as the "yeast," bringing innovation into mental health care.
The Mental Health Action Plan is somewhat more specific in its content. It recommends a series of actions under five key headings—to foster awareness of mental wellbeing, to tackle stigma, to implement comprehensive mental health services, to provide a competent workforce, and to recognise the experience and importance of service users and carers in planning and developing services.
From the perspective of a service user or consumer what is the importance of these recommendations? That a consumer role is given such prominence is both overdue and welcome, although these documents are noticeably vague on such details as how funding should be provided to initiate and consolidate service user groups, at the same time as respecting their autonomy.10 Further, no attention is given here to more complex questions of how the views of children, or those who lack capacity, can be represented. Little emphasis is placed in these documents on the mental health of the younger and older segments of the European population. On the positive side, the action plan actively encourages the use of legislation about disability rights in each member state of the European WHO region on an equal basis for people with disabilities related to physical illness or to mental illness.11
But do these polices go far enough? They tread a broad but often uneasy path between advocating for mental health promotion and prevention strategies for the whole populations (the focus of the European Commission), emphasising the need to respect human rights (the domain of the Council of Europe), and targeting services towards people with established mental illnesses in proportion to their degree of disability (a prime interest of WHO). These policies therefore do not state clearly whether or not treatment and care should take precedence over promotion and prevention. Most European countries cannot afford to do both of these activities well, and in some states few mentally ill people receive any effective treatment. A recent comparative international study of depression found that none of the patients in St Petersburg received evidence based treatment in primary care, and only 3% were referred on to specialist mental health care.12 The inability of patients to afford out of pocket costs was the primary barrier to care for 75% of the depressed patients studied.
This core issue of finance is dealt with well in these documents. WHO calls on European nations to make investment in mental health an identifiable part of health expenditure to achieve parity with investment in other areas of health. This has very important implications since mental disorders contribute about 12% to the global burden of disease, whereas European countries spend on average about 5% of their health budget on mental health care.6 The lowest reported budgets, at less than 2%, are all in the countries of the former Soviet Union.6 Such parity of expenditure is therefore a necessary ingredient to redress historical neglect of mental health, both East and West, for example within European Union Research and Development budgets. WHO is to be congratulated on stating the principle of parity in funding so unequivocally.
Graham Thornicroft, professor of community psychiatry
Health Service Research Department, Institute of Psychiatry, King's College London, London SE5 8AF (g.thornicroft@iop.kcl.ac.uk)
Diana Rose, co-director
Service User Research Enterprise (SURE), Health Service Research Department, Institute of Psychiatry, King's College London, London SE5 8AF
Figures 1 and 2 are on bmj.com
Competing interests: GT attended the WHO European Ministerial Conference as a temporary adviser to the World Health Organization.
References
World Health Organization. Mental health declaration for Europe. Copenhagen: WHO, 2005.
World Health Organization. Mental health action plan for Europe. Copenhagen: WHO, 2005.
Tomov T. Central and eastern European countries. In: Thornicroft G, Tansella M, eds. The mental health matrix. A manual to improve services. Cambridge: Cambridge University Press, 2001: 216-27.
World Health Organization. Mental health in Europe. Country reports from the WHO European network on mental health. Copenhagen: WHO, 2001.
Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence. Br J Psychiatry 2004;185: 283-90.
Knapp MJ, McDaid D, Mossialos E, Thornicroft G. Mental health policy and practice across Europe. Buckingham: Open University Press, 2005.
Amnesty International. Memorandum to the Romanian government concerning inpatient psychiatric treatment. London: Amnesty International, 2004.
Mental Disability Advocacy Center. Cage beds. Budapest: Mental Disability Advocacy Centre, 2003.
Social Exclusion Unit. Mental health and social exclusion. London: Office of the Deputy Prime Minister, 2004.
Chamberlin J. User/consumer involvement in mental health service delivery. Epidemiol Psychiatr Soc 2005 (in press).
Sayce L. From psychiatric patient to citizen. Overcoming discrimination and social exclusion. Basingstoke: Palgrave, 2000.
Simon GE, Fleck M, Lucas R, Bushnell DM. Prevalence and predictors of depression treatment in an international primary care study. Am J Psychiatry 2004;161: 1626-34.
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