World Health Organization's Annual Report Focuses on the Burdens and Costs of Mental Illness

In early October the World Health Organization (WHO) released its annual report on world health. The report, Mental Health: New Understanding, New Hope, begins with the following statement: "In devoting the World Health Report 2001 to mental health, WHO is making one clear emphatic statement. Mental health—neglected for far too long—is crucial to the overall well-being of individuals, societies, and countries and must be universally regarded in a new light."

The report focuses primarily on the global toll of seven common disorders that usually cause severe disability: depressive disorders, schizophrenia, substance use disorders, epilepsy, mental retardation, disorders of childhood and adolescence, and Alzheimer's disease. In describing the magnitude of the disease burden associated with mental illness, the report notes that one in four people will suffer from a mental or neurological disorder at some point in their life. Neuropsychiatric disorders account for nearly a third of the disability in the world. A total of 450 million people worldwide are currently affected by these disorders—121 million people suffer from depression and 24 million from schizophrenia. Each year one million people commit suicide, and 10 to 20 million attempt suicide. Depression is expected to rank as the second leading cause of global disease burden by 2020, second only to ischemic heart disease.

A primary message of the report is that the magnitude of the problem is not matched by the size and effectiveness of the response it demands. Currently 33 percent of countries do not have a specific mental health budget within their overall public health budgets. Another 33 percent allocate less than 1 percent of their overall health budgets to mental health. The remaining countries allocate less than 5 percent. The report also points out that about 40 percent of countries do not have an explicit mental health policy. In about 25 percent of countries the most commonly prescribed drugs to treat schizophrenia, depression, and epilepsy are not available at the primary care level. More than half of the countries in the world have only one psychiatrist per 100,000 people, and 40 percent of countries have less than one hospital bed per 100,000 people that is reserved for patients with mental disorders.

The report calls governments "the ultimate stewards of mental health" and places the responsibility for action squarely on government leaders. One key issue highlighted repeatedly in the report is the importance of shifting care away from large psychiatric institutions and creating a range of community mental health services. The report notes that in 38 percent of countries community mental health care is unavailable. It outlines three scenarios for action that governments can adopt, depending on their level of resources. The report makes clear that even in poorer countries whose resources are very limited or nonexistent, some steps can be taken.

Ten recommendations for action are outlined for all countries to follow.

• Provide treatment for mental disorders within primary care.

• Make psychotropic medicines available.

• Provide care in the community, replacing large custodial institutions with community facilities.

• Educate the public about mental illness.

• Establish national policies, programs, and legislation.

• Develop human resources by training mental health professionals.

• Link mental health with other social sectors.

• Monitor community mental health.

• Support more research.

The report is part of the organization's year-long campaign to focus the attention of world leaders and policy makers on the global toll of mental illness and neurological disorders. For the first time in the organization's history, multiple events at WHO, including its premier report, technical discussions at the World Health Assembly, and World Health Day, celebrated on April 7, 2001, have all focused on one topic—mental health.

Mental Health: New Understanding, New Hope is available on the WHO web site at www.who.int/whr.

CMHS Releases Biennial Report

The Center for Mental Health Services has released Mental Health, United States 2000, a compendium of the latest available information on mental health services, published every two years since 1983. According to the report, 5,722 mental health organizations were operating in 1998. These organizations maintained a total of 261,903 inpatient and residential treatment beds. Inpatient and residential treatment admissions totaled 2,313,594, and admissions to other services totaled 3,967,019. Episodes of care in mental health organizations reached 10,714,398.

State mental health agencies expended more than $16 billion for mental health services in 1997, compared with $12.1 billion in 1990. However, when adjusted for inflation, actual expenditures decreased by 7 percent between 1990 and 1997. Community-based services accounted for 56 percent of total expenditures in 1997 and state mental hospitals for 41 percent. The report cites the sources of funding for state agencies as follows: state government tax revenue, $11.4 billion; the federal government, principally through Medicaid, $4 billion; first- and third-party payments, $822 million; and local government, $95 million. The Community Mental Health Services Block Grant accounted for 2.4 percent of state expenditures in 1990 but only 1.5 percent in 1997, according to the report.

For the first time, the report includes chapters on co-occurring mental and addictive disorders, refugee mental health services, rates of psychiatric problems among children and adolescents, mental health services in juvenile justice facilities, performance indicators for state mental health agencies, and new data standards for mental health services.

The report makes four major predictions for the future of mental health services. First, human rights will be established as fundamental in the health care system. Second, consumers and family members will seek and will be given more responsibility for health and health care. Third, technology will become a primary vehicle for delivering health care. Finally, genetic treatments for mental disorders will become routine.

Copies of Mental Health, United States 2000 can be ordered by calling the CMHS Clearinghouse at 800-789-2647.

News Briefs

Recent GAP report captures powerful voices of consumers: In 1994 the committee on psychiatry and the community of the Group for the Advancement of Psychiatry asked Dear Abby to place an item in her column requesting that people diagnosed as having schizophrenia write in to describe their experiences with psychiatrists and psychiatric treatment. Using excerpts from the more than 500 letters it received, the committee has created an informative and often moving report that captures the voices of consumers and offers a unique perspective on the experience of managing a painful mental illness. The 46-page report, which is designed as a brochure, will be distributed widely to psychiatrists and psychiatric residents as well as to policy makers and other mental health professionals to help convey the important message that psychiatric treatment must be sensitive to the whole person and must focus on an individual's strengths and potential. Publication and distribution of the report were funded through an unrestricted grant from Janssen Pharmaceutica, Inc. To obtain a copy of the report, contact the Committee on Psychiatry and the Community, GAP, P.O. Box 28218, Dallas, Texas 75228.

National research initiative on co-occurring disorders: Rand Health, in collaboration with the Robert Wood Johnson Foundation and the John D. and Catherine T. MacArthur Foundation, is undertaking a national research initiative to lay the groundwork for the evaluation and diffusion of best practices in the treatment of co-occurring mental and addictive disorders. As part of the initiative, Rand is seeking examples of innovative organizational, financial, or system designs believed to have improved care for this group in both the private and the public sector. For more information about the initiative or to report on innovative models, contact Nancy Pollock at Rand, 201 North Craig Street, Suite 102, Pittsburgh, Pennsylvania 15213-1516; 412-683-2300, ext. 4945; e-mail, [email protected].

Applications available for Lilly scholarships: Eli Lilly and Company has announced that applications for the 2002-2003 Lilly Reintegration Scholarship Program are available. Now in its fourth year, the scholarship program helps persons with bipolar disorder, schizophrenia, and schizophrenia spectrum disorders acquire the educational and vocational skills they need for reintegration into society. An independent panel of nine mental health professionals chooses the winners on the basis of several criteria, such as involvement in rehabilitation and success in dealing with their disease. Last year scholarships were awarded to 76 students, many of whom are repeat winners successfully continuing their education. For more information or to request an application, call 800-809-8202. The application deadline is January 31, 2002.

NARSAD calls for award applications: The National Alliance for Research on Schizophrenia and Depression has announced award opportunities of up to $50,000 a year for 2 years (maximum $100,000) to enable scientists at the academic level of associate professor or equivalent. Research must be relevant to schizophrenia, major affective disorders, or other serious mental illnesses. Guidelines and an accompanying face sheet are available at www.narsad. org. The application submission deadline is March 5, 2002. For more information, contact Audra Moran at 516-829-5576 or [email protected].

People & Places

Appointments and retirement: This month Steven E. Hyman, M.D., will assume the office of provost of Harvard University. Dr. Hyman has served as director of the National Institute of Mental Health since 1996. In November Alan Leshner, Ph.D., left the National Institute on Drug Abuse, which he had directed since 1994, to become chief executive officer of the American Association for the Advancement of Science. Several weeks earlier, Enoch Gordis, M.D., retired as director of the National Institute on Alcohol Abuse and Alcoholism. He had led the institute since 1986.