Principles of Social Psychiatry

37 The psychiatric–child protection interface: research to inform practice Colin Pritchard School of Health and Social Care, Bournemouth University, Bournemouth, UK One of the basic markers of any civil society is its compounded by differing explanations for psychoso- capacity to look after its most vulnerable members. cial pathology, especially when complicated by sub- Children’s basic needs are often affected by a number stance abuse and/or underlying personality disorders. of factors including poor parenting, abuse (physical These conditions tend to be associated with violent and sexual) and bullying at school. The protection of and abusive sexual behaviour. At the extremes of child children using the legal system provides a safety net. neglect and abuse is the death of a child, with a However, since ‘child protection’ became more spe- disproportionately high frequency of mentally ill par- cialized in the 1970s, a clear understanding of the ental assailants. The psychiatric dimension in this importance of the psychiatric–child protection inter- interaction is consequently far greater than previously face has been lost. Each service’s priorities can and realized. A better understanding of the psychiatric– often do create a potential conflict of interest between child protection interface will enable us to reduce the professionals acting primarily in the interests of either fatal toll, make children safer and prevent some future an adult patient or an at-risk child. This confusion is psychiatric problems. 37.1 DILEMMAS IN PSYCHIATRY AND CHILD PROTECTION: A CASE EXAMPLE A fictionalized account of a recent problematic child- history of psychiatric illness, having access to their custody case is used here to illustrate the relevant children, aged eight and ten. The paediatrician issues. This case set consultant paediatrician and emphasized that as the father had been violent psychiatrist against each other, as an estranged wife towards his wife and the children had witnessed sought to prohibit her ex-husband, a patient with a verbal threats of violence against their mother and Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

484 SOCIAL INTERVENTIONS her new partner, contact between the father and the while the risk of suicide by the father outweighed children was causing serious distress, resulting in other considerations. Conversely, the paediatrician marked deterioration in their school work, increasing maintained that the children’s emotional and physical anxiety, sleep disturbances, enuresis and a worsening condition was being jeopardized by a father who was relationship with peers. The paediatrician recom- still intermittently using drugs and alcohol and whose mended that the court enforce the mother’s applica- threats of violence should be taken seriously. The tion to stop her husband’s right to access. On the tragic events unfolded over the last weekend before other side, the consultant psychiatrist presented evi- the court case when the father killed his children and dence of major progress in the stability of the 45- then himself. year-old father, who was devoted to his children, and This illustrates how the psychiatric–child protec- argued that loss of access would make him a real tion interface is often misunderstood. There is con- suicide risk, given his previous history of serious siderable evidence that at the extremes of child suicide attempts. The father had been diagnosed as abuse, resulting in the death of a child, a vast suffering from Munchausen syndrome while in his majority of assailants are family members, predo- late twenties, but he had shown no symptoms of this minantly those in parenting roles [1,2], of whom for the past five years. Furthermore, although the many have underlying mental health problems [3–6]. father had been violent towards his wife, there was no However, the psychiatric–child protection interface evidence of violence towards his children and there often remains unacknowledged [4,7]. This was epi- was a bond of real affection between them. The tomized in a confidential audit of violence and paediatrician and psychiatrist each argued that their mental disorder in the UK, in which it appears that primary responsibility was to their respective clients. the age and relationship of the victims to the men- The psychiatrist asserted that the ‘paramount’ inter- tally disordered assailants was not recorded or at ests of the children were not being served by loss of least not reported [8–10]. A proper understanding of contact with an undoubtedly loving father and that this relationship is crucial in developing prevention the children’s current problems were resolvable, and intervention strategies. 37.2 BACKGROUND In the UK, under the Infanticide Act, mothers who kill effects on the development of children and adoles- their babies (<1 year) are considered to be mentally cents. This was reflected in a so-called definitive disordered and unfit to plead, the assumption being review of child abuse in the British Journal of Social that the mother must be experiencing a post-partum Work, which made no mention of any issues relating psychosis. Before the early 1960s, the concept of to mental health [14], despite there being evidence that ‘child abuse’ was not widely known and it was not inappropriate and exploitative child/parent/adult rela- until Kempe et al. [11] alerted the Western world to tionships can be particularly corrosive to the child’s ‘baby battering’ that the issue started to receive wider mental health development [2,15,16]. public attention. In the UK, the Maria Colwell enquiry However, the psychiatric–child protection inter- in 1973 highlighted something of the extent of the face is far more subtle and extensive than just dealing problem, with great emphasis being placed on the with mentally disordered perpetrators of abuse (in all most extreme outcome of child abuse, i.e. the death of its forms). It is this complexity that is explored in the child [1,12,13]. examining the impact of psychiatric disorder upon There has been a tendency to play down both the child living with a mentally ill parent, along with mental health and social (i.e. poverty) factors in child the impact of child neglect and abuse as a factor in abuse, especially in relation to ‘emotional’ abuse, subsequent mental disorder and psychosocial which can often have relatively worse long-term pathology.

THE PSYCHIATRIC–CHILD PROTECTION INTERFACE: RESEARCH TO INFORM PRACTICE 485 37.3 ATTACHMENT AND DEVELOPMENT The attachment and developmental problems often with 12 controls identified early relative neurological experienced by children of a mentally ill parent are dysmaturition in six of the index group, of whom five supported by the ‘Every Child Matters’ Agenda in the went on to develop a schizophrenic-spectrum disorder UK, which seeks to integrate all services relevant to asanadult[27].Thestudyincludedexaminationsat2,6 children to ensure their fivemain needs are met: ‘being and 13 months and psychological testing at ages 10, 15 healthy,stayingsafe,enjoyingandachieving,makinga and 22 years, with follow-up to age 27–35 years. This positive contribution and economic well-being’ [17]. suggests that a mother with a schizophrenia-spectrum Psychosocialhealthanddevelopment,leadingtoevery disorder and her child should receive maximum sup- child achieving their full potential, are undoubtedly portandassistance asearlyaspossible.Althoughthese important.Variousfactorsplayaroleinattachmentand numbers are small, the trends do indicate that phychia- development, as discussed below. trists and clinicians need to be aware of parenting issues.Similarly,studiesconcernedwithparentalalco- hol and/or substance abuse have shown an association 37.3.1 Neurodevelopment with delayed or impaired neurological development and possible links with later attention-deficit and The negative effects of maternal, family and socio- hyperactivity (ADHA) syndrome in children [28,29]. economic stressors upon the child’s neurological developmentarenowbeingempiricallydemonstrated. Maternal stresses retard the neurological development 37.3.2 Psychosocial of the under one-year-old baby, affecting both brain development and subsequent behaviour [18–20]. With Psychosocial factors are also relevant. To take a small our greater ability to measure and monitor subtle and number of indicative examples: (i) Pollock and previously indiscrete reactions, it is now possible to Percy [30] examined 40 pregnant women and their investigate the biological underpinnings for Bowlby’s attitudes to their developing foetus. They found that theories of attachment and for links between early negative attitudes were associated with poor attach- abuse and later depression. For example, there is now ment but not with reported intention to harm the research suggesting that high levels of cortisol in foetus; (ii) an intriguing example of global maternal response to stress may increase risk of depres- stress came from the Netherlands where, following the sion [21–23], with the intriguing possibility that this Nazi invasion in 1940, significantly higher rates of increased stress responsivity stems from experiences subsequent schizophrenia were found among people of abuse in childhood [24]. Equally there are well- born that year [31]; (iii) the Ice Storm in Canada in established neurodevelopmental markers associated 2000, which caused enormous disruption, was asso- with the aetiology of schizophrenia, such as those ciated with poor cognitive development in chil- found in studies of parental infection, of obstetric dren [32], which was still identifiable (in comparisons complications and of how visual disturbances in early with control cohorts) five and a half years later [32]. childhoodpredictschizophrenic-spectrumdisordersin These select examples indicate that social and cultural adulthood [25,26]. A remarkable longitudinal study of contexts are important in understanding the impact of 12 infants of mothers with schizophrenia compared environment on child development. 37.4 THE IMPACT OF LIVING WITH MENTALLY DISORDERED PARENTS Manfred Bleuler [33], in a classic and influential parent? Children sometimes have to cope with acute paper, asked what was it like to live with a psychotic disturbances in their parents, reversing the child/

486 SOCIAL INTERVENTIONS adolescent–parent role, to care and protect their par- Baby Unit found that mothers with schizophrenia ents from the potential consequences of their dis- were reported as having poorer interactions with turbed behaviour [34,35]. Thus there is a need for their children. A British study followed 239 mothers mental health services to initiate support for children with schizophrenia and 693 mothers with affective coping with the ‘burden of mental disorder’ [35,36], disorders over 8 years to examine the quality of their with an urgent need to develop partnerships across parenting [40]. These authors found that the mothers services [37]. This is complicated by the fact that with schizophrenia had higher ratings for poor par- children born to mothers with psychosis are exposed enting skills and, crucially, psychosocial problems, to multiple risks: genetic predisposition, suboptimal using social services criteria, when compared with development and the burden of having to confront affective disordered mothers. However, if the former mental illness daily [38]. had a well partner and a supportive relationship or The detrimental effects on child development are belonged to a higher social class, then the outcome confirmed by a number of studies. For example, Wan was better. Thus, even in the presence of schizophre- et al. [39], in a study of 38 Manchester women with nia, social factors remain important, and given ade- perinatal mental illness (13 with schizophrenia and 25 quate and appropriate support those with a serious with affective disorders) admitted to a Mother and mental disorder can be effective mothers. 37.5 CHILD SEX ABUSE AND SUBSEQUENT OUTCOMES The impact of child neglect and abuse into adulthood child and adolescent maladjustment and subsequent has been reported from many cultures. Baloobal psychosocial problems, including substance abuse et al. [41] noted a link between child sexual abuse and its link with suicide. A key feature to emerge is and people attending an adult psychiatric clinic in the the young person’s markedly low ‘self-esteem’. Sal- West Indies. Gladstone et al. [42] in Australia and zinger et al. [50] investigated severe physical abuse of Peleikis et al. [43] in Norway also reported an asso- pre-adolescents in a study of 75 young people at ages ciation between sexual abuse as a child and depression 10 and 16 years and found a strong association with and anxiety states as adults. depression and suicidal behaviour. Thus there is an From an investigation of 263 adolescent females urgent need for clinicians to be aware of the long-term who had reported ‘unwanted sexual experiences’, impact of severe physical maltreatment on suscepti- Kogan [46] found that the age at which disclosure bility to mental illness. became possible was crucially affected by the rela- There is, moreover, evidence that adolescents who tionship to the perpetrator – the closer the relation- run away from home and adolescents who become ship, the greater the delay in admitting their distress. homeless are more likely to have experienced sexual While most studies of child sexual abuse report that victimization in childhood [51–54]. the child is more disturbed by a ‘within-family’ A complicating factor in all these associations is the assailant than by an ‘extra-family’ abuser, the major- overlap between socioeconomic disadvantage and ity of men charged with a sex offence against a child psychopathology, as well as physical injury [55–60]. are ‘extra-family’ molesters, leading us to the con- Freisthler et al. [61] studied 1646 children to explore clusion that ‘within-family‘ abuse is underreported the relationship between socioeconomic markers and in official crime statistics. This may be because once childhood injuries. They found disproportionate num- the abuse is discovered in the family, it is often bers among those living in poverty, with substance stopped, so the family is reluctant to go to the abusing parents, and from ethnic minority groups – a authorities [1]. de facto surrogate indicator for poverty, especially in A link between earlier child abuse and suicidal the US [62]. It may well be that there is a degree of behaviour has been widely reported [47,48]. underreporting, as suggested by Everson et al. [63], Makhija [49] noted the crossover between child abuse, who examined 350 adolescents (11–13 years) who had

THE PSYCHIATRIC–CHILD PROTECTION INTERFACE: RESEARCH TO INFORM PRACTICE 487 been identified as at risk of abuse before the age of the adolescents’ self-reported rates were 4 to 6 times two. When compared with ‘official’ records of abuse, higher than the child protection records. 37.6 PERSONALITY DISORDERS: THE CHASM BETWEEN PSYCHIATRY AND CHILD PROTECTION Neglecting and abusing parents often came from an 22% of the gender difference with regard to violence. intergenerational cycle of being neglected, abused and Crucially, while the rates for alcohol, drug dependence sometimes from residential homes where abuse may and antisocial personality disorder were relatively low, have occurred [1,2,15,16,64–66]. Poverty, with all its only 7, 4 and 4%, respectively, they disproportionately negative health features, also plays a role, thereby contributed to a higher risk of violence – 23, 15 and complicating both aetiological and intervention 15%, respectively [74,75]. factors. This gender differential was also seen in a study of Broadly, child protection practitioners are inclined anxiety sensitivity in 245 monozygotic and 193 dizy- to view problematic parents as being on a temporal gotic twins. Women were more influenced by a com- continuum from previously disadvantaged ‘victims’ bination of environmental and genetic factors, to becoming in turn inadequate and eventually whereas men were more influenced by environmental neglecting or/and abusing parents. From disruptive factors [76]. This could mean that there are gender/ behaviours in childhood an individual may progress to genetic predispositions that interact with environmen- antisocial behaviour and criminal activity. This then tal influences. causes social services to have serious concerns about Frick and White [77] suggested that ‘callous these young men and women in their own right as well unemotional’ traits were important in the develop- as possible future inadequacies in their role as parents, ment of aggressive and antisocial behaviours, which causing a vicious cycle of deprivation [54,67–71]. are seen in an important subgroup of antisocial and aggressive youth. However, Pardini et al. [78], in a follow-up of 120 highly aggressive 5th graders over a 37.6.1 Psychiatric perspectives on year, reported that such traits, although fairly stable, personality disorder were not immutable as callous unemotional children exposed to lower levels of physical punishment and higher levels of parental warmth and support showed Personality disorders are discussed at length else- later decreases in the levels of these traits and anti- where in this volume (see Chapters 19 and 34). Is social behaviour. Conversely, children with ‘low personality disorder a ‘learned’ or inherent behaviour, warmth’ parents had increased callous unemotional shaped by the environment, albeit with possible traits, again showing the nurture–nature interaction. genetic predisposition [72]? The evidence suggests This indicates that there are suitable interventions and an interaction of all these factors. Suffice to say that educational packages that can be used to modify the most useful practical aspect of the concept of outcomes in the longer term. personality disorder is the relative stability of so- called borderline personality disorder [73]. There are obvious gender differences, as highlighted by Coid et al. [74] and Yang and Coid [75]. In these studies, 37.6.2 Developmental perspectives on men were more likely to meet criteria for antisocial personality disorder personality disorder as per ICD 10, and more likely to be violent and misuse substances, whereas women As noted earlier, the relationship between childhood appeared to have more anxiety states. These authors abuse and eventual adult personality disorders has further found that psychiatric morbidity explained been confirmed in several studies [79–85]. A Finnish

488 SOCIAL INTERVENTIONS ‘FromBoy to Man’ studytraced2556boysaged 8 in related to perceived parental care (self-esteem), adoles- 1981 until early adulthood, focusing upon externa- cent peer relationships and eventual adult relationships, lized (conduct disorder) and internalized (anxiety and personality styles [87]. This reflects Quinton and disorder) psychopathology, based upon military, Rutter’s[65]classicoutcomestudyofformeradolescent health and offender records [86]. These authors females in children’s orphanages. In this study, those found that boys with both externalized and inter- with positive key personal relationships did as well as nalized disorders had the worst outcomes in that they theirsocialpeersasmothers,whereasthosewithoutany had high rates of criminal behaviour and mental significant relationships went on to repeat neglectful disorders. Although these boys represented only parentingstyles.Johnsonetal.[52,53],inacommunity- 4% of the total sample, they were responsible for based study of 593 families, traced children from 6 to 26% of all crimes and as many as 62% had subse- 14–16 years old. They found strong correlations quent mental disturbances. Internalized problems betweenlowparentalaffectionandantisocialbehaviour, alone had the relatively best outcomes and the borderline personality disorder and other mental dis- authors recommend that if these children can be orders. Those exposed to harsh parenting were at espe- identified early enough, it should be possible to cially high risk for personality disorder, passive aggres- break this vicious cycle [86]. sive traits and schizotypy. While there was a degree of A follow-up study from the Isle of Wight on adoles- overlap, broadly affectionless parenting was associated cent psychopathology traced former disturbed adoles- withmorepersonalityproblems,butitwashavingharsh cents into mid-life. While 10% of individuals had aggressive parents that was particularly linked to later reported severe sexual or physical abuse and had higher antisocial and aggressive personality disorder rates of subsequent adult mentaldisorders, a substantial types [52,53]. Therefore, it ought to be possible to minorityofabusedindividualsreportednomentalhealth intervene early enough and improve some if not all of problems. This apparent ‘resilience’ was reportedly these outcomes. 37.7 CHILD VICTIM TO ABUSER Briere et al. [81] found, from a sample of 1442 in the finding [79,80,82,83,88–91]. A British study found US that 14% of men and 32% of women satisfied some that almost half of convicted child sex offenders in criteria for sexual abuse. The respondents did not South East London had reported experiences of identify whether the abuse was within the family or sexual victimization, which was also associated outside the family. The authors therefore assumed that with a greater range of psychological distur- sexual abuse was relatively common in the general bance [92]. An earlier study compared a large population. However, these rates should be treated number of criminal histories of validated cases of with caution in terms of negative outcomes on chil- childhood sexual abuse with cases of physical dren, as much of the abuse is often ‘casual’ and does neglect or abuse, and with a matched socioeconomic not continue over time or involve the child in a control group. This found that there was little dif- corruptive and manipulative way. It has been found ference between the control and index groups for that many extra-family abusers have predominantly later delinquency and adult crime, but the previous casual sexual contact with many different children, victims of child sexual abuse had a considerably often only a one-offs, which helps them avoid higher rate of arrest for sexual crimes than con- detection [1,5]. trols [83,89–91]. Burton [90] compared 74 male It has been argued that male children who are the prisoners who had been involved in a sex crime victims of previous abuse are particularly likely to against a child with 53 matched nonsexual abusing become abusers, although this is not a universal prisoners and noted that it was possible to identify

THE PSYCHIATRIC–CHILD PROTECTION INTERFACE: RESEARCH TO INFORM PRACTICE 489 76% of the child sex abusers as being earlier victims were found guilty of a sexual offence, mainly against of sexual abuse and physical neglect. Thus, there is a a child and predominantly outside the family. They seriouslinkbetween beinga victim andbecominga had experienced three times the material neglect, perpetrator [15,71,93]. lack of supervision and witnessing of serious intra- Perhaps the most convincing study of the journey familial violence and seven times the rate of being from abused to abuser is that of Salter et al. [94], who cruel to animals as children. A majority of abused prospectively assessed childhood experiences in a children do not go on to become abusers, but parti- longitudinal study over 7–19 years and included 224 cular patterns in their childhood appear to be asso- male victims of child sexual abuse. Based upon ciated with a greater risk of becoming perpetrators in criminal convictions, 12% of the victimized men later life [94]. 37.8 EXTREMES OF THE PSYCHIATRIC–CHILD PROTECTION INTERFACE In many countries, including Britain, ‘child one conviction for serious violence, and were protection’ in the public mind is to do with its fail- thus described as ‘violent multicriminal’ child sex ures [95]. At the time of writing, the case of Baby P, abusers [103]. An analysis of a decade of child whose mother, cohabiter and male lodger were homicides distinguished between within-family or responsible for the child’s death, caused a massive extra-family assailants [1,5]. outcry, as did the killing of the two Mullings-Swell children by their mother who had a psychotic dis- order [96,97]. Although the extremes of child neglect 37.8.1 Within-family assailants and abuse is a death of a child [13,15,98], the causative and contributory factors are many. A majority of Of this group of assailants, 82% were parent figures the perpetrators are family members, mainly parent and these could be categorized as: parents with a figures (85–90%) [1,99–101]. likely mental disorder, mothers on the At Risk of Cavanagh et al. [102] explored in detail 26 cases Abuse Register (ARAR) and stepfathers/cohabitees of fatal child abuse by a father. The fathers were with a pervious conviction for violence. The most poorly educated, underemployed and had signi- frequent within-family assailants were mentally ill ficantcriminalhistories.Amajority,62%,were mothers (MIMs) 44%, followed by ARAR mothers ‘stepfathers’, although only four perpetrators were 33%, followed equally by mentally ill blood fathers married to the child victims’ mothers, confirming 22% and stepfathers/cohabitees 22%. This initial earlier observations of a decade of child homicide analysis, showing 66% of assailants to have been assailants [5]. A psychiatric dimension in cases of mentally ill, was a matter of concern, as it might add the deaths of children is even more central than in the to the stigma surrounding those with a mental dis- neglect and abuse continuum. In a two-year study of order [1,72]. However, an epidemiological analysis UK convicted male child sex abusers, it was possible of rates of killings rather than absolute frequency to identify three behavioural types. A majority produced a very different pattern. The MIM homi- (54%) had no other police convictions other than cide rate, at 100 per 100 000, was half that of mothers a sexual offence against children and were desig- on the ARAR. The presence of a ‘violent’ man, i.e. a nated as ‘sex only’ offenders. The second group stepfather/cohabitee with a previous conviction for were all convicted of nonsexual crimes in addition violence, was 4 times more common than an MIM. to at least one sex offence against a child, designated However, all these men were jointly charged with as ‘multicriminal’ child sex abusers. The final group their female partners, who in each case were also on were convicted of nonsexual crimes and had at least the ARAR, because at the trial it was not possible to

490 SOCIAL INTERVENTIONS determine which parent was primarily responsible 37.8.2 Extra-family assailants for the death of the child [104]. Interestingly, in most casesthemother wasgiven a 2-to3-yearsentencebut These were all male violent multicriminal child sex the violent father-figure was given 12 to 15 years, abusers (VMCCSAs) and although they were the indicating whom the judge thought was the smallest group of assailants, their epidemiological main assailant. It is noteworthy that the best rate was 80 times that of the MIM. Clearly, in terms predictor of subsequent violence is an earlier violent of risk and rate of child murder VMCCSAs are sig- offence [105,106]; hence both psychiatric and child nificantly more of a physical threat to children than protection services need to know about any previous MIM [1,100]. These men raise serious ethical issues in convictions of nonblood father-figures living with how they should be dealt with that need to be discussed children under 5 years. and resolved. 37.9 IS THE PSYCHIATRIC DIMENSION PREDOMINANT? A majority of parents who killed their children were there was any indication of improved child protec- mentally ill: all the blood fathers and a fifth of the tion [62,117–119]. UNICEF [120] argued that child MIM killed themselves after killing their child, while mortality is an indicator of how a society meets the another fifth of mothers were involved in a nonfatal needs of its children and the accepted view is that suicide event. This is the classic suicide after murder violent deaths of children are the extreme conse- dyad [107–109]. Murder-suicide has been reported in quence of child neglect and abuse [1,13,98]. In an many cultures [110,111]. intriguing study of ‘unnatural causes’, of death in The VMCCSA are men who, almost by definition, Danish children, carried out in conjunction with the are seriously personality disordered and may be British National Confidential Enquiry team, Webb described as ‘callous unemotional’ types [77,78], et al. [121] noted that the highest observed risk of with the origins of their dysfunction lying in their violent death to children came from parents, espe- backgrounds [74,75,79–85]. Yet they may be cially if they had a previous psychiatric history. Of ‘mentally competent’, aware that what they did to course, the strength of the psychiatric dimension may their victims was wrong and not the result of some come down to how one defines ‘personality disorder’ deluded and/or hallucinatory state or the exercising and its origins, as many themselves experienced of sexual fantasies [112,113]. Nevertheless, inter- neglect and abuse [74,75,79–85], or what might be ventions to reduce reoffending have had some mod- described as earlier ‘failed’ child protection. Thus it erate success [114–116]. appears unequivocal that the psychiatric–child protec- Earlier research into child protection measured tion interface is of vital importance to safeguarding the violent deaths of children, to determine whether children. 37.10 MORE PSYCHIATRIC COMPLEXITY In the Wessex study it was shown that all blood parents suicide register, based upon Coroner’s information, to who killed one (or more) of their children had a high compare suicide rates in the general population, those level of subsequent suicide, but none of the extra- related to mental disorder and any linked to child sex family assailants were known to be involved in abuse, both as victims and perpetrators [122,123]. suicidal behaviour [1]. One unexpected factor was Although the Coroner’s court records did not have the high level of suicide amongst the ‘sex only’ child comprehensive information on previous child sex sex abusers [5]. This led to an analysis of a regional abuse of suicide victims, nonetheless there was no

THE PSYCHIATRIC–CHILD PROTECTION INTERFACE: RESEARCH TO INFORM PRACTICE 491 equivocation about the accuracy of the suicide rates of intervention with sex abusers is to challenge their the child abusers. denial that their behaviour harms their victims. Treat- Female victims of sexual abuse had four times the ment to reduce these men’s reoffending rates has suicide rates of the general population, male victims improved but there is still a need for further six times that of their peers, but both victim groups had advances [114–116]. Perhaps the most complex and far less than mental-disorder–related suicides. How- controversial area of psychiatric–child protection is ever, the child sex perpetrators’ suicides, all of whom the ‘Munchausen syndrome by proxy’ [124], now were ‘sex only’ offenders, had a rate four times that of designated ‘fabricated–induced illness syndrome’. the mentally disordered [122]. While half of these Although relatively rare, it has been reported in more men’s suicides surrounded either the disclosure of than 20 countries [125,126]. Further detailed analysis their offence or occurred at the beginning of their of these cases and their clinical findings is necessary in trials, the apparent ‘remorse’ may, and it is stressed order to understand the implications of such a may, be an important treatment indicator. A key diagnosis. 37.11 CONCLUSIONS The association between mentally disorder and Health and social care should work with domestic within-family assailants has been noted over the violence and child protection services in assessing the past two decades [3,4,6,113,127–131]. Recently, potential risk to children [10] but often this advice is Friedman et al. [129] noted that the vast majority ignored, despite the seminal work of Falkov [4] and of adult psychiatrists never explore the issue of the disproportionately high level of mentally dis- whether a patient with psychosis who has children turbed parents involved with the unnatural deaths of ever thought of harming their child. This may be children, as found by the NCI team [40,121]. Reflect- because, as with suicide ideation, there is a reluc- ing on the range of research that highlights the impor- tance to inadvertently put the idea in the person’s tance of the psychiatric–child protection interface, head. Yet it would seem that where the patient with a what undermines this essentially integrated approach psychosis or personality disorder has children at is the degree of specialization and subspecialization in home, especially if the patient is also involved in medicine. This is exemplified by the tacit Cartesian substance abuse, the risk to their child should be a separation of mind and body and the tendency for serious consideration. psychiatry to want to find ‘the cause’ or a specific With careful, sensitive, unthreatening or intrusive ‘medical’ explanation. The best in modern psychiatry exploration about possible ideas of self-harm, the is a meeting of the sciences and arts, as it seeks to psychiatrist must also explore any violent feelings understand how individuals respond to developmen- the patient may have about their family members. In tal and trigger events in their personal and social reviewing the Wessex work, it seemed clear that if contexts. adult psychiatrists with patients with psychosis or The psychiatric–child protection interface should personality disorder had asked themselves ‘is there be a model not only for psychiatry but also for the rest a child protection issue here’ and social workers had of medicine, as it reminds the practitioner that the asked themselves whether there was a mental health particular client/patient with whom they are working problem, many of the children who did may not have is at a specific time point along a continuum in their died [1,72]. About half the eventual parent assailants lives. The neglected and abused child is the parent of showed significant early warning signs, though some the future, while today’s parent–patient affects their showed overt levels of disturbance that involved their family. The potential strengthofmodernpsychiatry children barely a week or so before the fatal event, in adopting a biopsychosocial model, with a treat- giving the professionals virtually no chance to ment armoury ranging from CBT to psychopharma- intervene [1,128]. cology, is enhanced when it adopts a developmental

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Part Six Global mental health



38 Mental health in Europe: learning from differences Mirella Ruggeri and Maria Elena Bertani Department of Medicine and Public Health, University of Verona, Italy 38.1 INTRODUCTION One in four of European citizens will suffer from a influenceindepictingtheprioritiesandtheproblemsfor mental health problem during their lifetime. More mental health in Europe: (1) the Maastricht treaty in than 27% of adult Europeans are estimated to experi- 1992 founded the European Union (EU) with the ence at least one form of mental ill-health during any inclusion of 12 Member States: Belgium, France, one year, the most common being anxiety disorders Germany, Luxemburg, Holland, Denmark, Ireland, and depression [1]. In Europe mental disorders Italy, United Kingdom, Greece, Spain and Portugal; account for 20% of disability and, according to the (2) in 1995 Sweden, Finland and Austria entered the World Health Organization [2], by the year 2020, EU; (3) in 2004 Cyprus, Estonia, Latvia, Lithuania, depression is expected to be the highest ranking cause Malta, Poland,Czech Republic, Slovakia, Slovenia and of disease in the developed world. In spite of these Hungary entered the EU; and (4) Bulgaria and Romania data, the organization and funding for mental health finallyenteredin2007.Thus,in2009theEuropeanUnion services is widely heterogeneous throughout Europe was constituted by 27 State Members, while a further 25 and can be considered far from satisfactory. Europe States belonged to the geographic area of Europe. itself is a puzzle of different cultures, socioeconomic In the World Health Report entitled Mental Health: conditions, environmental situations and health orga- NewUnderstanding, New Hope,theWHOprovided 10 nizations. This notwithstanding, the last decades of recommendations for action [2]. These cover a variety the twentieth century and the beginning of the twenty- of topics ranging from care for the mentally ill in first have witnessed an historic attempt to unify this primary health services, the availability of psychotro- continent under common principles and initiatives, pic drugs, stakeholder involvement, the importance of while respecting each state’s autonomy. education and human resources to the issue of integra- The constitution of the European Union has taken tion with other services, and monitoring and research. place in four major steps which have had a profound At the WHO European Ministerial Conference on Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

502 GLOBAL MENTAL HEALTH Mental Health, held in Helsinki in January 2005, the between stakeholders in both the public and private Mental Health Declaration for Europe (http://www. sectors, may provide a useful blueprint for those euro.who.int/document/mnh/edoc06.pdf) and the seeking to collaborate to reform mental health systems Mental Health Action Plan for Europe (http://www. elsewhere [3]. euro.who.int/document/mnh/edoc07.pdf) were signed This chapter comprises seven parts, focusing on and endorsed on behalf of ministers of health of the 52 the main characteristics of mental health policies, Member States in the European Region. These key legislation, funding, service organization, resources, documents give impetus to the development of mental promotion of mental health and some other key data health care in the European region and aim to support aimed to link quantity of service provision with the implementation of policies and activities to quality and patient outcomes; it also enlightens the improve mental health promotion, prevention, care networking capabilities that exist in Europe in the and treatment. They centre on 12 key areas of action: field of mental health. In doing this we will explore (1) promoting mental well-being for all; (2) demon- differences within and between five main groups of strating the centrality of mental health; (3) tackling European countries: stigma and discrimination; (4) promoting activities sensitive to vulnerable life stages; (5) preventing Group A: constituting the 15 countries that entered mental health problems and suicide; (6) ensuring the EU by 1995; access to good primary care for mental health pro- blems; (7) offering effective care in community-based Group B1: constituting the 10 countries from eastern services for people with severe mental health pro- Europe that entered the EU between 2004 and blems; (8) establishing partnerships across sectors; 2008; (9) creating a sufficient and competent workforce; (10) establishing good mental health information; Group B2: constituting Cyprus and Malta, which (11) providing fair and adequate funding; and (12) entered the EU in 2004 but, for geographical and evaluating effectiveness and generating new evidence. historical reasons, should more appropriately be In June 2008, the European Commission (EC) considered in a different group from B1; hosted a High-Level Conference to discuss the estab- lishment of a new European Pact for Mental Health Group C1: constituting the 19 eastern and southern (http://ec.europa.eu/health/ph_determinants/life_style/ European countries of the EU region that are not in mental/docs/pact_en.pdf). The new approach recog- the EU; nizes that the primary responsibility for action still rests with Member States and other stakeholders, but Group C2: constituting Andorra, Iceland, Israel, envisages an active role for the Commission to inform, Monaco, Norway, San Marino and Switzerland, complement and encourage actions by these players, which also did not enter the EU but, for geogra- building coalitions for action across different sectors, phical and historical reasons, should more appro- with a focus on five key themes: (1) prevention of priately be considered in a different group from C1. suicide and depression, (2) youth and education, (3) workplace settings, (4) the mental health of older The main axes for this work will be the data people and (5) combating stigma/social exclusion. If reported and adapted from the Mental Health Atlas [4] successful, this Pact process, with its emphasis on plus further information derived from the literature facilitating multisector dialogue and cooperation and various Web-based searches. 38.2 FUNDS, RESOURCES AND COSTS OF MENTAL HEALTH SERVICES Within Europe there is a high variability in income countries in the low (L), low-medium (LM), high- among countries. Figure 38.1 shows the proportion of medium (HM) and high (H) ranges of Gross Domestic

MENTAL HEALTH IN EUROPE: LEARNING FROM DIFFERENCES 503 Group A Group B1 Group B2 Group C2 15 countries that entered 10 countries from eastern Cyprus and Malta that Group C1 constituted by Andorra, into the EU within 1995 Europe that entered in the entered the EU in 2004 but 19 eastern and southern Iceland, Israel, Monaco, EU in 2004-2008 for geographical and European countries of the Norwegia, San Marino, historical reasons considered EU region that are not in High income Switzeland also did not enter in a different group from B1 the EU High medium income the EU but, for geographical and historical reasons, should more Low medium income appropriately be considered in a Medium income different group from C1. Low income Figure 38.1 Income characteristics in the countries belonging to the European region (World Bank). Data are taken from Reference [4], modified Product (GDP) according to World Bank estimations in not have a specific budget dedicated to mental health each of the five groups of European Countries given in 2005. Overall, when a specific budget was dedi- above. cated to mental health, there was a large variability As shown in Figure 38.1 and detailed in Tables 38.1 among countries. In the EU Member States the range and 38.2, large disparities are found throughout varies from 0.0 to 13.4% of the total health budget, Europe: in fact, among the EU Member States, only with a mean of 5.8% in states that entered the EU Bulgaria and Romania are in the low-medium income before 1995, this being the highest value found among group, while the other eastern countries are in the the different groups of countries within the European medium-high, with the exception of Slovenia, which region. is in the high income group. In contrast, among As Figures 38.2 and 38.3 show, in the five dif- European countries that do not belong to the EU, five ferent groups of countries within the European have a low income (Albania, Kyrgystan, Moldova, region, there are remarkable differences concerning Tajikistan and Ubekistan). the proportion of the health budget dedicated to In comparison with other regions of the world, the mental health (see Figure 38.2). Figure 38.3 shows availability of resources for mental health care in that, when considering the proportion of per capita Europe is generally at the highest level, after the US. total expenditure on health and the budget for For example, in the European region, the specified mental health, the differences between Group A budget for mental health care as a proportion of the countries, on the one hand, and Groups B1 (eastern total health budget was <1% in only 2% of countries, countries belonging to the EU) and C1 (western and whereas this proportion was 17% across the world (all southern European countries not belonging to the regions), which implies that a dramatic funding short- EU) countries, on the other, are even more remark- age in mental health care applies to European coun- able, due to the very low health budget per capita tries much less frequently than in other regions of the assigned in the latter two groups. world [4]. However, resource levels vary widely The data confirm that share of health care funding is within the European region, with a number of eastern heterogeneous and, basically, that initiatives designed European countries in a more difficult situation con- are generally underfunded. The question of equitable cerning mental health funds [5]. As evidence from funding was recently addressed by the EC-supported Tables 38.1 and 38.2 (left-hand columns) shows, six Mental Health Economics European Network (www. EU Member States (Austria, Greece, Spain, Estonia, mheen.org),whichsoughttoestimatethelevelofhealth Poland and Slovenia) and 9 further countries outside care expenditure on mental health across 32 European the EU (Belarus, Bosnia-Herzegovina, Iceland, Rus- countries.Itcametotheconclusionthatavailablefunds sian Federation, San Marino Republic, Tajikistan, were modest at best, despite the ever-increasing evi- Turkey, Turkmenistan, Ukraine and Switzerland) did dence of cost-effective interventions [6,7].

504 GLOBAL MENTAL HEALTH 10 domestic of Number workers/ 100 000 inhabitants 103.4 — 7 150 — 477 56 47.7 6.4 35 176 1.6 — — 58 (1.6–477) 0.3 — — 1 0.5 — 0.6 — 1 0.45 (0.3–1) 0.6 25 3.1 14 the social 101.6 (b) of part); GDP ¼ gross Number psychologists/ 100 000 inhabitants 49 — 85 79 5 51.5 14 12.71 3.2 28 28 2 1.9 76 9 (2–85) 0.9 4.9 — 2 2 5 3.4 4.5 3 1.65 (0.2–4.9) 19.3 2.6 10.9 (upper 31.7 3 1997 L ¼ low; of Number nurses/ 100 000 inhabitants 37.8 — 59 180 98 52 3 136 32.9 35 99 10.1 4.2 32 104 (3–180) 15 33 0 19 40 36 18.4 8.9 32 5.8 (0–36) 45 102 73.5 and 63 20.8 1995 M ¼ medium; of psychiatrists/ 100 000 inh 11.8 18 16 22 22 11.8 15 6.82 9.8 12 9 4.7 3.6 20 11 (3.6–22) 9 12.1 13 9 10 15 6 4.1 10 5.35 (4.1–15) 5 4 4.5 between income; Number 12.2 9.3 EU in settings (0–7.5) (0–2.3) the H ¼ high Beds other (10 000 inhabitants) 0 6.6 7.5 1 2 — 4.1 1.28 3.7 0 2.3 4.9 0.1 — — 2.8 2.3 0.2 0 0.1 0 0.3 0.6 0.2 0 0 0.37 0 0 0 entered GH that hospitals; in Beds (10 000 inhabitants) 2 2.6 — 9 3 2.9 0.3 1.86 0.92 3 1 1 0.6 6 — (0.3–9) 2.6 1.9 1.5 2.1 7.2 0.3 1.1 1.2 2 3 1.26 (0.3–7.2) 0.6 0.04 0.3 countries eastern countries (middle part); and (c) the 2 islands with specific geographic and historical characteristics that entered the EU in 2004–2007 (bottom part). Data MH 2.15 15 GH ¼ general in (10 000 inhabitants) 4.5 12.9 — 0 7 4.5 4.3 7.45 0 7.5 15.4 1.5 3.7 — — (0–15.4) 4.1 9.8 8 2.3 13.5 8.6 5.2 5.5 6 7.2 (2.3–13.5) 4.5 18.86 11.7 the Beds 5.7 7 (a) in: hospitals; number beds of (10 000 inhabitants) 6.5 22.1 0.7 10 12 7.5 8.7 9.43 4.63 10.5 18.7 7.5 4.4 6 5.8 (0.7–22.1) 8.3 11.4 10.2 9.6 13.8 10 7.8 7.6 9 8.46 (8.3–13.8) 5.2 18.9 12 characteristics MH ¼ mental Total Funds MH No 6 P P 8 P No 6.8 3.5 13.4 7 2.3 No 8.9 (0–13.4) 2.5 3 No 8 6.3 7 No 3 5 No 9.61 (0–8) 7 10 8.5 resource modified. available for (%health budget) 11 10 5.8 3.5 and [4], not detail for Funds health GDP) (% 8 8.9 8.4 7 9.6 10.8 9.4 6.5 8.4 6 8.9 9.2 7.5 8.7 5.8 (6–10.8) 4.8 7.4 5.5 6.8 6.4 6 6.1 6.5 5.7 8.4 (4.8–8.4) 8.1 8.8 8.4 funds but 8.2 6.3 Income, Reference P ¼ present Income (World Bank) H H H H H H H H H H H H H H H LM HM HM HM HM HM HM LM HM H H H 38.1 from taken Austria Belgium Denmark Finland France Germany Greece Ireland Luxemburg Netherlands Portugal Sweden (range) Bulgaria Republic Estonia Hungary Lithuania Poland Romania Slovakia Slovenia (range) Cyprus Table are product; Country (a) Italy Spain UK Mean (b) Czech Latvia Mean (c) Malta Mean

MENTAL HEALTH IN EUROPE: LEARNING FROM DIFFERENCES 505 non-EU of Number workers/ inhabitants 0.4 0.08 0.3 0 0.03 — 0 — ? 1.5 0.5 1.2 — 1 — 0.4 0.1 (0–1.5) 26 110 5.18 81 — 54 106 (5.18–110) (b) social 100 000 0.4 63.6 and part) of psychologists/ 100 000 inhabitants 0.2 0.4 0.2 1.14 0.5 — — 0.1 0.4 2 0.7 1.9 0.1 1 — 0.06 0.05 (0.05–2) 30 60 35.6 33 68 96 40.8 (30–96) (upper available Number 0.6 51.9 EU not of (0–34) (0–46) the detail Number nurses/100 000 inhabitants 4.2 0 3.9 25.6 10 — 24 — 13.7 24 30.5 50 3.6 3 — 34 7.2 9 33 10.7 — 42 0 46 entered but 16.7 23.4 not P ¼ present of psychiatrists/ 100 000 inhabitants 2.2 4 5 10.1 1.8 8.7 6 6 4.5 7.5 9 13.3 1.8 1 3 8.9 3.3 (1–13.3) 10 25 13.7 28.5 20 15 23 (10–28.5) have Number 5.6 19.3 that product; other (10 000 countries in Beds settings inhabitants) 0 0 0.09 0 0.2 1.06 0.1 — 0 0 0.1 1 — 0 — — 0 (0–1.06) 0.3 0 0 0.1 0 — 0 0 (0–0.1) 0.01 European European countries with specific geographic and historical characteristics (bottom part). Data are taken from Reference [4], modified. MH ¼ mental hospitals; domestic in Beds (10 000 inhabitants) 0.5 0.02 0.11 0.5 1 0.98 0 0.2 0.63 2 0.8 0.5 — 0.5 0.3 0.3 0.1 (0.02–2) 1.6 5 0.4 17.27 — 3.8 0 (0–17.27) southern GDP ¼ gross in GH 0.5 4.6 and L ¼ low; Beds (10 000 MH inhabitants) 2 4.78 6.9 7.5 2.4 8.02 2 5.9 5.62 6.2 5.9 10.1 2.47 0.8 3.2 9.3 3 (0.8–10) 5.1 0 0 7.6 0 — 0 13.2 (0–13.2) 3.4 eastern beds (a) (10 000 inhabitants) 2.5 4.8 7.1 8 3.6 10.06 2.1 6.5 6.25 8.2 6.7 11.5 2.47 1.3 3.5 9.6 3.1 (1.3–10) 1.6 5 8.1 17.27 12 3.8 13.2 (1.6–17.2) in: M ¼ medium; Total 5.7 8.7 characteristics income; for Funds health (% MH budget) 6 4.5 1.6 No No P P 7 7.9 P 6.5 No No No No No 4.6 (0–7.9) 2.7 3.9 no 6.2 P 0.1 No No (0–6.2) 1.7 resource H ¼ high Funds health for GDP) (% 3.7 7.8 1.6 5.6 7.5 9 3.6 3.1 4 6.8 5.7 5.4 3.3 5 4.1 4.3 3.6 (1.6–9) 5.7 9.2 8.7 7.6 8 6.8 11 (5.7–11) and hospitals; Income (World Bank) L LM M LM LM HM LM LM L LM L LM L LM LM LM L 4.9 H H H H H H H 8 Funds 38.2 GH ¼ general Albania Armenia Azerbaijan Belarus Bosnia- Herzegovina Croatia Georgia Kazakhstan Kyrgystan Macedonia Moldova Russian Federation Tajikistan Turkey Turkmenistan Ukraine Uzbekistan (range) Andorra Iceland Monaco Norway Marino Switzerland (range) Table Country (a) Mean (b) Israel San Mean

506 GLOBAL MENTAL HEALTH Figure 38.2 Budget for mental health as a proportion of total health budget in five different groups of countries. Dots under the 0 line represent countries that do not have a specific budget for mental health. Data are taken from Reference [4], modified Figure 38.3 Budget for mental health as a proportionoftotalhealthbudgetpercapitain fivedifferentgroupsofcountries.Dotsunder the0linerepresentcountriesthatdonothave a specific budget for mental health. Data are taken from Reference [4], modified

MENTAL HEALTH IN EUROPE: LEARNING FROM DIFFERENCES 507 Table 38.3 Policies, legislation and models of community care in: (a) the 15 countries that entered the EU between 1995 and1997 (upper part); (b) the 10 western countries; and (c) the 2 islands that entered the EU in 2004–2007 (bottom part). Data are taken from Reference [4], modified Formulation Formulation of national Year of initiation Presence of of MH MH programme of the latest community Country policy (year) (year) law in the field of MH care facilities (a) Austria 1999 1997 1997 Yes Belgium 1988 1990 2000 Yes Denmark 1991 1997 2002 Yes Finland 1993 1999 1990 Yes France 1960 1985 2005 Yes Germany 1975 Absent 1999 Yes Greece 1983 1984 1999 Yes Ireland 1984 Absent 2001 Yes Italy 1994 1999 1998–2000 Yes Luxemburg 1995 1991 2000 Yes Netherlands 1999 1999 1994 Yes Portugal 1995 1996 1998 Yes Spain 1985 Absent 1986 Yes Sweden Absent Absent 2000 Yes UK 1998 1999 Proposal to reform Yes (b) Bulgaria 2004 2001 1973 No Czech Republic 1953 1953 1966? Yes Estonia 2002 Absent 1997 Yes Hungary 2001 2001 1997 Yes Latvia 2004 2004 1997 Yes Lithuania 1993 1999 1995 Yes Poland 1995 1995 1994 Yes Romania 1998 1999 2002 No Slovakia Absent 1995 2004 Yes Slovenia Absent Absent 1999 Yes (c) Cyprus 1985 1995 1997 Yes Malta 1994 Yes (details not available) 1981 Yes The personal, social and economic impacts of poor much as 80% of all costs of poor mental health [9]. mental health can be profound. The economic costs Other impacts outside the health system can of poor mental health have been estimated at 386 include poor personal relationships and strain on billion euros (2004 prices) in the EU countries, plus families [10–12], a higher than average risk of home- Norway, Iceland and Switzerland [8]. Costs of lost lessness [13] and increased contact with the criminal productivity from employment can account for as justice system. 38.3 POLICIES, LEGISLATION AND MODELS OF PSYCHIATRIC CARE According to the Atlas [4], governments in 70.1% 89.1% of the population, have developed mental of countries in the European region, which covers health policies, and this compares favourably

508 GLOBAL MENTAL HEALTH Table 38.4 Policies, legislation and models of community care in: (a) the eastern and southern European countries that have not entered the EU (upper part) and (b) non-EU European countries with specific geographic characteristics (bottom part). Data are taken from Reference [4], modified Formulation of Formulation of national Year of the latest MH policy MH programme reform law Presence of Country (year) (year) in the field of MH community care (a) Albania Absent Yes (details not available) 1996 Yes Armenia 1994 Absent 2004 Yes Azerbaijan Absent Absent 2001 Yes Belarus Absent Absent 1999 Yes (partially developed) Bosnia- 1996 1996 2000 Yes (partially developed) Herzegovina Croatia Absent Absent 1997 Yes Georgia 1999 1995 1995 No Kazakhstan 1997 Absent 1997 Details not available Kyrgystan 2000 2000 1999 No Macedonia Absent Absent ? Yes Moldova 2000 Absent 1998 No Russian 1995 1995 1992 Yes Federation Tajikistan Absent Absent Details not available No Turkey 1983 A-1987 — No Turkmenistan 1995 Absent 1993 — Ukraine 1988 Absent 2000 No Uzbekistan 1993 Absent 2000 — (b) Andorra Absent Absent — Yes Iceland Absent 2001 1997 Yes Israel 1999 Absent 2000 Yes Monaco 1995 Details not available 1981 No Norway 1997 1999 2004 Yes San Marino Absent Absent — Yes Switzerland Absent Absent 1981 Yes with the world average of 62.1%. As shown in panorama was completely different, with only Tables 38.3 and 38.4, these policies are relatively 11 countries having well-developed community recent, most having been established after 1990. facilities (Albania, Armenia, Azerbajan, Croatia, Community care facilities are widely available in Macedonia, Russian Federation, Slovakia, Andorra, Europe (overall in 79.2% of countries, and speci- Iceland, Israel and San Marino). Europe is also fically in 99% of the EU and 60% of the non-EU the continent where specific mental health legisla- countries), and these estimates compare favourably tion is more frequently present (91.8% of coun- with the other continents, including the Americas tries). In the vast majority of European countries, (75%). In 2005, among EU Member States, only recent reforms to mental health law have been Bulgaria and Romania had not developed commu- enacted, most frequently after 1995 (see Tables 38.3 nity care facilities; among non-EU countries the and 38.4).

MENTAL HEALTH IN EUROPE: LEARNING FROM DIFFERENCES 509 38.4 SERVICE PROVISION AND OUTCOMES According to the Atlas [4], Europe has a much higher community [16]. In most non-EU countries the number of psychiatric beds per head of the population above-mentioned problems are even more wide- (8/10 000 inhabitants) than in the rest of the world. At spread and severe. a world level, country income is certainly a major Availability of mental health professionals is higher determinant of number of beds (higher income, higher in Europe compared with the rest of theworld, with 9.8 number of beds). When income differences are not psychiatrists per 100 000 of the population, 24.8 very high, it is clear that models of psychiatric care nurses, 3.1 psychologists and 1.5 social workers. As might also intervene in determining the absolute shown in Tables 38.1 and 38.2 (right-hand columns), number of beds and the places where they are located. there is a marked heterogeneity among countries, both In fact, due to the uneven presence of community in the number of mental health professionals and in the facilities, in Europe a remarkable proportion of beds proportion of different professions. Community and are still in psychiatric hospitals (63.5%) and only institutional psychiatry throughout Europe are evi- 21.8% are in general hospitals. When considering the dently based on similar models, but these models are total number of beds in the five different groups of put into practice in different ways, according to the European countries, as reported in Tables 38.1 cultural norms, requirements and choices of each and 38.2 (right-hand columns), a variable picture specific country. emerges. Among EU Member States, the highest A major problem in the current debate, and also in number of beds is found in eastern Europe (9.61/ the delivery of mental health care, is scarce aware- 10 000 inhabitants) and in Cyprus and Malta (12/ ness of a key point spelled out by Thornicroft [17]: 10 000 inhabitants). In non-EU eastern and southern community care ‘... is a service delivery vehicle. It Europe countries, which have the lowest income, the can allow treatment to be offered to a patient, but is number of beds is low (5.7), but 89% are located in not the treatment itself’. This distinction is impor- psychiatric hospitals. The percentage of beds in psy- tant, as the actual ingredients of treatment have been chiatric hospitals is 64% in western EU countries and insufficiently emphasized and evaluated. During the 70% in eastern EU countries [14,15]. These estimates last decade, international mental health services show that at the European level psychiatric care research at the European level has been intensified, provided inside institutions is still frequent. That said, and some comparative data on the relationships it is also true that, overall, there has been a decline in between service provision and service outcome have the use of psychiatric beds in many EU countries over been published. Until the mid-1990s a great number the last 30 years; moreover, where long-stay care is of studies analysed the consequences of deinstitu- provided, this is now much more likely than before tionalization on the lives of mentally ill patients at the to be in general hospitals rather than specialist national level in several countries, mainly in the psychiatric institutions. However, much remains to UK [18,19], but also in Italy [20] and Sweden [21]. be done. There has been little change in the balance However, the scope for comparing results of these of care in some of the new Member States, e.g. studies was limited due to the use of different meth- Bulgaria, Latvia and Romania, and serious con- ods and study designs. Meanwhile, the international cerns persist about the human rights and dignity standardization of methods for the assessment of of those residing in institutional care facilities in mental health services has been considerably several of the new EU Member States: large-scale improved and some European multicentre studies, isolated institutions, some with 1000 beds or more, either naturalistic or experimental, on the use and the may be of very poor quality, giving no thought or outcomes of mental health services have been concern to individual privacy or to investment in later implemented. This is witnessed by a series of activities to help individuals reintegrate into the projects with a focus on social psychiatry, which

510 GLOBAL MENTAL HEALTH involve several European sites that have been pub- patients from the different countries were small but lished since 2000. We report here examples from social differences between the samples where three observational and three experimental European detected and seem likely to be due more to social multicentre studies. context. 38.4.1 Naturalistic studies 38.4.2 Experimental studies The EPSILON Study (European Psychiatric Ser- The EQOLISE trial (Enhancing the Quality Of vices: Inputs Linked to Outcome Domains and Life and Independence of persons disabled by severe Needs) [22] was conducted in five European centres mental illness through Supported Employment) [25] (Amsterdam, Copenhagen, London, Santander and assessed the effectiveness of the individual place- Verona). It produced standardized European ver- ment and support (IPS) programme in helping people sionsofsix instrumentsinkey areasofmental with severe mental illness gain open employment health service research (psychopathology, needs for and examined whether its effects were modified care, quality of life, service satisfaction, carer by local labour markets and welfare systems. It burden and costs) in five languages, and compared included 312 patients with severe mental illness data from five European countries regarding 404 randomly assigned in six European centres (the UK, patients with schizophrenia and mental health care Italy, Germany, the Netherlands, Switzerland provision and costs. The instruments developed and Bulgaria) to receive IPS or vocational services. were reliable across the range of countries and The study demonstrated the effectiveness of IPS will facilitate future comparative health service in widely differing labour markets and welfare research. contexts. The ODIN Study (Outcomes of Depression Inter- The EDEN Study (European Day Hospital Eva- national Network) [23] examined the use and cost of luation Study) [26], a multicenter randomized con- services by adults with depressive or adjustment dis- trolled trial, was conducted in five European Centres orders in five European countries (Ireland, Finland, (Germany, the UK, Poland, Slovakia and the Czech Norway, Spain and the UK) and predictors of outcome Republic) to establish the effectiveness of acute day in 427 patients. Severity of depression, perceived hospital care in a sample of 1117 voluntarily health status, social functioning and level of social admitted patients across a range of mental health support were significant predictors of service use. The care systems. Day hospital care was as effective as number of people able to provide support was posi- conventional inpatient care with respect to psycho- tively associated with greater health service use. pathologic symptoms, treatment satisfaction and Individual participant factors provided greater expla- quality of life. It was more effective in improving natory power than national differences in health care social functioning at discharge and at the 3- and 12- delivery. month follow-up. The EuroSC (European Schizophrenia Cohort) [24] The Quatro Study (Quality of Life following had the primary objective to relate the types of treat- Adherence Therapy for People Disabled by Schizo- ment and methods of care to clinical outcome. Sec- phrenia and their Carers) [27] aimed to evaluate the ondary objectives included the assessment of treat- effectiveness of adherence therapy in improving ment needs in relation to outcome, the calculation of quality of life for people with schizophrenia. It resource consumption associated with different meth- was conducted in five European countries (the ods of care and the identification of prognostic factors. UK, Spain, Italy, Germany and the Netherlands) The study was conducted in nine European centres, and found that adherence therapy was no more located in France, Germany and Britain. The clinical effective than health education in improving quality and sociodemographic differences between 1108 of life.

MENTAL HEALTH IN EUROPE: LEARNING FROM DIFFERENCES 511 38.5 PREVENTION AND PROMOTION ISSUES ACROSS EUROPE Mental health promotion aims to protect, support and information in the 28 European countries on poli- sustain emotional and social well-being and create cies, programmes, workforces and infrastructures for individual, social and environmental conditions that prevention and promotion in mental health (http:// enable optimal psychological and psychophysiologi- www.gencat.cat). Overall, analysis of promotion and cal development, enhance mental health, while show- prevention in the various European countries showed ing respect for culture, equity, social justice and that, across all countries, there is some activity being personal dignity. Prevention of mental disorder undertaken on prevention and promotion in mental focuses on reducing risk factors and enhancing health, and some coordinated and sustained actions protective factors, with the aim of reducing risk, based on evidence, while other actions are more ad incidence, prevalence and recurrence of mental dis- hoc and require increased support and sustainability. orders, the time spent experiencing symptoms, and The availability of practice, the resources allocated decreasing the impact ofillness on the affected person, and the infrastructures developed vary across coun- their families and society [28]. This topic has been tries, reflecting different health care systems, poli- recently brought to the attention of the European tical histories and the traditions and understandings Commission, which adopted a Green Paper on of mental and public health. The variations across Mental Health in October 2005 (http://ec.europa. European countries imply that there are different eu/health/ph_determinants/life_style/mental/green_ starting points for action in prevention and promo- paper/mental_gp_en.pdf) designed to highlight the tion in mental health, but also common challenges. importance of mental well-being and develop a com- Although there is a variety of existing implemented prehensive EU strategy on mental health. practice, this does not guarantee its positive impact; Strong evidence has demonstrated that mental it is crucial that programmes for implementation are health promotion and mental disorder prevention based on evidence, are evaluated and are continu- work across the lifespan, providing cost-effective ously improved. A number of factors hinder pro- outcomes [29] (see also Chapter 30). As a matter of gress, and each of these can be identified as targets fact, the level of mental health and well-being in the for action: lack of conceptual clarity, a difficulty in population is a key resource for the success of the EU gathering information, a lack of data on mental as a knowledge-based society and economy [30]. health and, where available, difficulties in compar- Despite the acknowledgement of the importance of ability across countries, a lack of clear infrastruc- prevention and promotion by politicians and policy tures for prevention and promotion in mental health makers, it appears not to be a priority and there is a and a paucity in training the workforce and scarce lack of concerted action. support for implementation. The Implementing Mental Health Promotion The gaps that have been identified in countries can Action (IMHPA) was created in 2002 with the be tackled and closed, frequently by strengthening and financial support of the European Commission. With building on what already exists and by working in the participation of 28 European countries, it pro- partnership across different sectors [31]. At the Mem- vides a European platform that combines support for ber State level, it is crucial to develop clear action policy priority-setting and the dissemination of evi- plans, based on the evidence for prevention and dence-based knowledge on prevention and promo- promotion, that can guide the decision-making pro- tion in mental health and constitutes a unique data- cess of implementation. There is an urgent need to base for policies and information in this area. support implementation in all countries through, for Among the Actions implemented, IMHPA started example, guidelines and tailored tool-kits for imple- the process of assessing the situation across mentation. Evaluation urgently needs to be strength- the European Union Member States by collecting ened within Member States and Europe as a whole,

512 GLOBAL MENTAL HEALTH including evaluating the impact and cost effectiveness to the following ten action areas: (1) support parenting of prevention and promotion interventions across and the early years of life; (2) promote mental health different settings, using appropriate and well- in schools; (3) promote workplace mental health; (4) designed methodologies. support mentallyhealthy ageing; (5) address groups at European resources and infrastructures should be risk for mental disorders; (6) prevent depression and identified to provide a European framework and to suicide; (7) prevent violence and harmful substance support cooperative projects, research, monitoring, use; (8) involve primary and secondary health care; information collecting and sharing across countries. (9) reduce disadvantage and prevent stigma; and (10) European countries should develop and implement an link with other sectors. These actions should be actual action plan for mental health promotion and implemented by following these five common prin- mental disorder prevention based on country needs ciples: (1) expand the knowledge base for mental and priorities. health; (2) support effective implementation; (3) The action plans that each European country should build capacity and train the workforce; (4) engage develop and implement for mental health promotion different actors; and (5) evaluate policy and pro- and mental disorder prevention have to pay attention gramme impact [32]. 38.6 EUROPEAN SOCIETIES AND ASSOCIATIONS IN THE FIELD OF SOCIAL PSYCHIATRY The increasing perception of Europe as a unitary The Nordic Association for Psychiatric Epidemiol- community and the widespread impact of commu- ogy (NAPE) (www.nape.dk) was founded in 1997 and nity-based approaches in mental health have covers Sweden, Norway, Denmark, Finland and favoured the foundation of several organizations and Iceland. The aims of the NAPE are: to promote networks among European countries, whose cultural research of psychiatric epidemiology in the Nordic background is rooted in the frame of the social countries, especially recruitment and guidance of psychiatry approach. In this section we will summar- young researchers within the field; to promote the ize some of these organizations. The list is cooperation in the Nordic countries within the field; to not intended to be exhaustive of all organizations help ensure posts of psychiatric epidemiology in the working in Europe and includes only associations Nordic countries; to stimulate researchers of psychia- that involve more than three different European tric epidemiology to increase international coopera- countries: tion; and to stimulate the use of results of psychiatric The Section of Epidemiology and Social Psychiatry epidemiology research in the Nordic countries. of the Association of European Psychiatry (http:// The European Network for Mental Health Service www.aep.lu/about/sections/Epidemiology%20Sec- Evaluation (ENMESH) (http://www.enmesh.eu) was tion/index%20epidemiology.html) was founded in established in 1991 under the auspices of the World 1988. The Section promotes and supports psychiatric Health Organization, Regional Office for Europe. It is research to which epidemiology is a relevant tool. The a network of active researchers in the field of mental most relevant fields of interest are: genetic research, health service research and evaluation. The network is health economy research, health service research, informal in its structure, culture and organization. Its longitudinal research, outcome studies, pharmacoe- aims are: to develop and maintain a network of pidemiology, population surveys, register research active researchers in mental health service research and social psychiatry. Moreover, as one of its in Europe; to promote the development and dissemi- major objectives, the section supports and promotes nation of study designs, research instruments, mental younger colleagues within psychiatric epidemiologi- health outcome indicators (including cost measure- cal research. ments) and relevant forms of statistical indicators; and

MENTAL HEALTH IN EUROPE: LEARNING FROM DIFFERENCES 513 to function as a clearing house for mental health The European Society for Traumatic Stress Studies service evaluation information in Europe. Moreover, (ESTSS) (http://www.estss.org/) was established in the main activities are: to organize an international 1993 and is the European network for professionals in conference every second year – where researchers the field of psychotraumatology. The aims of ESTSS meet, network and discuss research-related issues; to are: to ensure that clinical research and policy run and update every second year a register of practices in the field of psychotraumatology are researchers active in the field of mental health service informed by evidence systematically gathered and research and evaluation; and to maintain an internet publicly scrutinized; to ensure continued prominence website to inform of activities within and linked to is given to all aspects of traumatic stress and its many ENMESH. repercussions; and to promote networking between The Open Society for Mental Health Initiative individuals and organizations within the field of (OSMHI) (http://www.osmhi.org/) works in central psychotraumatology. and eastern Europe and the former Soviet Union. It The European Alliance Against Depression aims to ensure that people with mental disabilities (EAAD) (www.eaad.net) is an international network (mental health problems and/or intellectual disabil- of experts with the aim to promote the care of ities) are able to live in the community and to depressed patients by initiating community-based participate in society with full respect for their intervention programmes in 17 European countries. human rights. The focus of OSMHI activities is to It is committed to the care of depressed patients and end the unjustified and inappropriate institutionali- prevention of suicidality in Europe. This aim is zation of people with mental disabilities. To reach being realized by implementing community-based this purpose, the MHI promotes de-institutionaliza- intervention programmes on four different levels. tion and the development of sustainable commu- The basic concept of the foour-level approach is nity-based services as a matter of policy across the based on the experiences of the ‘Nuremberg Alli- region, working at both national and European ance Against Depression’, a study that has recently levels. been conducted in the framework of the ‘German The European Federation of Associations of Research Network on Depression and Suicidality’ Families of People with Mental Illness (EUFAMI) (funded by the German Federal Ministry of Educa- (http://www.eufami.org/) was founded in 1990 with tion and Research). the aim to support family carers of people with mental The Implementing Mental Health Promotion illness throughout Europe. EUFAMI has members in Action (IMHPA) (www.imhpa.net) (noted above) was 26 European countries and one non-European country. created in 2002 with the financial support of the The aims are: to coordinate and provide for the European Commission. With the participation of 28 cooperation of the member associations by exchan- European countries, it provides a European platform ging experience and information; to defend the rights that combines support for policy priority-setting and and protect the interests of the family members of the dissemination of evidence-based knowledge on mentally ill people, and of the mentally ill people prevention and promotion in mental health, and con- themselves, to enable them to achieve the fullest stitutes a unique database for policies and information possible life in society; to represent the family asso- in this area. IMHPA has developed a European action ciations in any official European bodies in order to plan for mental health promotion and mental disorder establish the rights and interests mentioned above; to prevention and a policy framework identifying high- stimulate research into the causes, prevention, treat- priority policy initiatives to improve mental health, ment and consequences of mental illnesses for the based on their proven efficacy and the practicality of family members concerned and the mentally ill people their implementation. The purpose of such coalitions themselves; and to collaborate with scientific research is to exchange information on mental health promo- bodies and to build up a positive image concerning tion and prevention of mental disorders, to build mental illness, and counter social prejudice in this cooperation and to stimulate developments at national regard in society. and regional levels.

514 GLOBAL MENTAL HEALTH 38.7 MENTAL HEALTH IN EUROPE: NEW OR OLD PROBLEMS? Mental health in Europe is today in an evolving treatment in some countries that have already gone situation. People living in Europe are experiencing through de-institutionalization processes [14,15]; (v) the consequences of societal transition. This is occur- lack of receptiveness and substantial hostility in com- ring in eastern European countries belonging to the munities towards people with mental illness; and (vi) former Soviet Union, which have become newly critical issues regarding the quality of care and quality independent, in central Europe, where dramatic of life and turnover in some of the new residential changes have occurred during the last decade, but services that host people with long-term mental health also in Western Europe, where risk populations are problems. In a general sense, there is a high priority exposed to changes, regarding perspectives, identity, for rebalancing care concerning health expendi- possibilities for lifespan planning and predictability in ture [3], use of beds [14,15], human rights, gender life. Increasing burden and distress are influenced by differences [36] and discrimination against older peo- social exclusion, identity loss, lack of coherence and ple and minorities [37]. meaning, and existential emptiness [33]. Mental dis- While the reform process in western Europe has not orders, especially depression and suicide, and the been completed, the political changes in eastern Eur- consequences of risk-taking behaviour and destruc- ope and the enlargement of the European Union pose tive life styles, have become one of the greatest – new challenges for the modernization of mental health maybe the greatest – health care burden in countries of care systems in those countries [38,39]. More than a societal transition and in populations at risk (such as decade after the breakdown of the totalitarian political adolescents, the elderly, migrants and women). systems, many eastern European countries are still In the last 50 years the development of mental confronted with problems similar to those in western health services in western Europe has been character- Europe at the beginning of the reform process in the ized by conceptual and structural changes [34] that early 1960s, such as concentration of care in large have brought a radical transformation in mental health psychiatric hospitals and lack of outpatient facilities care provision. However, in most of these countries and other forms of community care [16]. However, in mental health care provision is still a multifaceted contrast to western Europe in the 1960s, many eastern picture and mental health reform has not yet been European countries at present are also confronted with completed, even if in most countries the majority of a dramatic lack of health care resources because of people with severe mental illness are now treated by economic deterioration, on the one hand, and an community services. The availability of effective increase of mental disorders at least partly because of psychotropic drugs was a further decisive factor con- social instability, on the other hand [40]. Under these tributing to the reform efforts and success, but eco- circumstances the context of mental health care reform nomic, social, cultural and political factors also sus- is different – and probably more disadvantageous – tained this long-term trend in societies [16]. from the situation in western Europe in the 1960s, Fakhoury et al. [35] pointed out that there have been which was characterized by economic prosperity and weaknesses in the de-institutionalization process, spe- social stability. For this reason a sustained effort should cifically concerning: (i) difficulty in meeting the needs be promoted at the European level to favour exchange for care of so-called ‘new chronic patients’ or of those of experiences, evaluative efforts, methodologies and with comorbid disorders, particularly those with sub- intensive networking among professionals in the field stance abuse comorbidity; (ii) an increasing pressure of mental health. Although the tendency for the homo- on the secure and forensic mental health care system; genization of different systems of care in Europe, as (iii) accumulation of ‘new long-stay patients’ and help well as of most aspects of societal sectors and values, is given to people with learning disabilities; (iv) an in place, a long road remains to be made in order increasing emphasis on the issues of involuntary to achieve real homogeneity between mental health

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39 East meets west: current mental health burdens in greater China 1 Roger M. K. Ng and Zhanjiang Li 2 1 Department of Psychiatry, Kowloon Hospital, Kowloon, Hong Kong 2 Beijing Anding Hospital, Capital Medical University, Beijing, People's Republic of China 39.1 CHINA: A VAST AND HETEROGENEOUS COUNTRY UNDERGOING RAPID AND TREMENDOUS CHANGES The societal transformation of China from the First and market economy in the 1980s, there has been a Opium War (1839–1842) to the current day can only steady improvement in economic and social struc- be described as immense and unimaginable. Under the tures and circumstances for the general public. By rule of the corrupt Qing Dynasty (1648–1912), fol- 1996, China’s economy had become the fastest lowed by the political upheavals during the period of growing one in the world. More than 300 million the Republic of China (established 1912) and second Chinese living along the coast have witnessed the Sino-Japanese War (1937–1945), China was consid- economic boom. Those 900 million Chinese living ered the ‘sick man of Asia’. During the Japanese inland are also experiencing slower but still impress- invasion of China, 20 million were killed and tens of ive improvements in their daily living conditions. In millions uprooted. The psychological aftermath of contrast, around 150 million of the rural population such a traumatic period is largely unknown, as there has become economic migrants, part of the ‘floating’ are no authoritative data that document the extent and population that lives at the fringes of the prosperous severity of mental health problems in this tragic period coastal cities like Shanghai and Shenzhen. They are at of Chinese history (see Reference [1] for a more risk of unemployment, poor health care provisions, comprehensive review). and poor housing conditions (see the section on Since the establishment of the People’s Republic of migration and mental health below in Section 39.7). China in 1949, China also witnessed unprecedented Furthermore, there are still an appreciable number political, economic and social changes. From the of Chinese who are living in the poorest rural areas early stage of Maoist communism in the 1950s to with very limited access to education and health the 1970s, to the introduction of an open-door policy services. Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

518 GLOBAL MENTAL HEALTH There is a strong legacy of epidemiological chotic disorders and fivefold for neurotic disorders), research on mental disorder in China. Even in the points to the heterogeneity of the epidemiology of late 1950s, early efforts were made to ascertain the mental illnesses in China. rates of mental illnesses in Beijing and Changsha. By This chapter will explore the current structure of the 1970s, epidemiological studies were initiated in mental health services in China, some of the major various parts of China. In 1982, with the assistance of mental health problems facing modern China the Mental Health Programme at the World Health (namely suicide, depression, psychosis and addiction Organization, a large-scale epidemiological survey problems) and the possible impact of globalization was conducted in 12 different sites in China [2,3]. (or Westernization) on the occurrence and presenta- There was an overall low prevalence rate of mental tion of mental illnesses in China. The final section illness (rates 3–5 times lower than in the West) and the will discuss the implications of economic growth, often substantial differences across different centres in particular its effects on migrant workers within (a threefold difference between populations for psy- China. 39.2 CURRENT MENTAL HEALTH BURDEN AND SERVICE STRUCTURE IN CHINA 39.2.1 Current mental health burdens Furthermore, in the 1990 survey, only 5% of people in China suffering from depressive disorder or bipolar affective disorder had received adequate treatment (compared In the Global Burden of Disease Study, mental health with 35% in most developed countries), while only problems and suicide constituted 18% of the disease 30% of people suffering from schizophrenia received burden in China [4]. It was also estimated that, by the proper treatment [4]. year 2020, mental health problems and suicide would The World Mental Health Survey, a 14-country continue to rise and constitute 20% of the disease epidemiological survey of the prevalence of mental burden (25% of the total disease burden for the female disorders, found that: around 7% of the subjects in population in China). It is worth noting that accidental China (n ¼ 5201) suffered from neurotic disorders, of which 2% suffered from depressive disorder; 1.9% injury, cardiovascular diseases andrespiratory diseases suffered from specific phobias; 1.6% from alcohol ranked second, third and fourth as causes of disease abuse; and 0.8% from generalized anxiety disorder. burden in China. As discussed by Phillips [5], most of Such point prevalence estimates can be translated into these morbidities were related to lifestyle problems a figure of around 68 million people in China suffering like smoking, reckless driving and poor dietary habits. from a neurotic disorder [7]. However, only 11% of Such behavioural problems are closely related to the subjects with neurotic disorders sought help from mental health of the community. If the first five causes medical professionals, implying that around 56 million of disease burden were added up together, they would sufferers did not receive any medical treatment. For constitute up to 50% of the disease burden in China. those seeking medical treatment, around 50% received These figures suggest that mental health interventions should be considered priorities for public health care in general hospital outpatient departments policy and prevention strategies. Among the mental while 37% consulted psychiatrists or counsellors. As health problems, the most prevalent disorders were in other Western countries, primary care physicians major depressive disorder (6.9%), bipolar affective have limited knowledge and skills in detection and disorder (1.9%), schizophrenia (1.3%) and obsessive- appropriate interventions for psychiatric disorders [8]. compulsive disorder (1.3%) [6]. It is estimated that It is apparent that China has a tremendous burden depressive disorder will be the third most important of mental disorder and, as discussed in the sections public health problem in China by 2020, while suicide below, this may be increasing in this fast developing will become the sixth most important problem. country.

EAST MEETS WEST: CURRENT MENTAL HEALTH BURDENS IN GREATER CHINA 519 39.2.2 Availability of psychiatrists and major cities. Mental health institutes in the provinces psychiatric beds or major cities constitute the top tier of the system and are responsible for enacting management guidelines Apart from the rising mental health burden, China, and providing guidance and support to all mental like many developing countries, is facing a severe health services in the area. The middle tier (town or shortage of skilled mental health professionals and district level) comprises mental health institutes in bed provisions. The number of psychiatric beds per medium-sized cities (still with populations of several 10 000 persons in China in 2004 was 1.1, representing millions) or psychiatric hospitals in towns and rural only 5% of total inpatient beds in China (compared areas. The bottom tier based in the community offices with 7.7 beds per 10 000 persons in the US). The and villages employs mental health field workers with number of psychiatrists per 100 000 persons in China responsibilities similar to community psychiatric was only 1.3, whereas the corresponding figure in the nurses (albeit without formal qualifications) in the US is 13.7 [9]. Only 1% of the total one million West. Mental health workers provide regular support medical graduates in China took up a career as a and contact with patients and their caregivers, and psychiatrist [10]. Apart from the shortage of beds and deliver some forms of rehabilitation. Over time, the skilled mental health professionals, there is also a Chinese government has successfully implemented concern about the variable standard of care provided. this three-tier mental heath system in most cities in At present, there is no national accreditation mechan- China [13]. Such a structure is crucial in the delivery ism in place that assesses the level of competence of of interventions to local populations. One crucial psychiatrists in China, leading to a wide variation in obstacle, however, in the delivery of mental health the quality of care delivered by psychiatrists and services is the fee-for-service system in most hospi- mental health professionals in different areas [5]. As tals in China. Since the introduction of an open market a remedy to this issue the Ministry of Health has economy, most hospitals have become self-sufficient started to develop a three-year clinical training pro- financially and have adopted a marketing strategy of gramme for specialist psychiatrists. Such programmes prioritizing services for people with secure medical are now being piloted in many major cities in China. insurance or stable employment. As most patients There is also active interest in developing a national with severe mental illness are likely to be unemployed accreditation system for specialist psychiatrists in and financially dependent on their families, many China, which is similar to those currently implemen- hospitals are reluctant to provide such mental health ted in the West. In addition to the lack of qualified services with a limited return on investments [5]. staff, most psychiatrists are based in psychiatric hos- One major step forward in the care delivery model pitals or general hospitals in cities, where pay and in China would be the national provision of free working conditions are better, leading to a persistent mental health services for people suffering from shortage of qualified professionals working in smaller severe mental disorder. More financial resources counties and rural areas [5]. must be invested by the government (the current mental health budget constitutes only 2.4% of the total expenditure on health care) and by other national 39.2.3 Current mental health care or private organizations. provisions in China As Hong Kong was under British rule for more than 100 years, psychiatric services in Hong Kong fol- It is estimated that over 90% of Chinese patients with lowed closely the British model of psychiatric care, severe mental disorders are receiving care from with free mental health services guaranteed for peo- family members, due to a lack of residential services ple with financial difficulties [14]. Before the return in the community [11]. Since the early 1990s, an of sovereignty to China in 1997, training of psychia- integrated mental health care system has been gra- trists in Hong Kong followed closely the British dually developed throughout China [12]. This is a model and attainment of a membership qualification three-tier model centred on provincial capitals and of the Royal College of Psychiatrists was a prerequisite

520 GLOBAL MENTAL HEALTH for recognition as a specialist psychiatrist in Hong Hong Kong is still a major obstacle in the develop- Kong. Since the handover back to China, Hong Kong ment of new services, especially the implementation has set up its own College of Psychiatrists to maintain of comprehensive community care [15]. By the end professional standards. Similar to the situation in of this decade, it is likely that there will be 3 psy- mainland China, the recruitment of medical graduates chiatrists per 100 000 persons in Hong Kong, reflect- into the speciality remains a major challenge. A ing a real shortage of trained psychiatrists in shortage of psychiatrists and mental health nurses in Hong Kong [14]. 39.3 SUICIDE: A MAJOR PUBLIC HEALTH ISSUE IN CHINA The World Health Organization (WHO) estimated 39.3.1 Reasons for the rising trend that suicide claimed one million lives in 2001, which of suicide: social fragmentation exceeded the number of deaths by homicide and war and loss of cultural values? combined [16]. Half of all female suicides in theworld occur in China [4]. In China, suicide is the fifth most Traditional Chinese culture is a high-context culture common cause of death in the country, accounting for comprised of an extended relationship network of more than 287 000 deaths per year [17,18]. The WHO family and kin living in close proximity to each other. 1999 World Health Report suggested that suicide is An individual’s self and self-worth is connected to China’s fourth most important public health problem others through well-established and well-understood in terms of disability-adjusted life years (DALYs) commitments, loyalties, rights and responsibilities. lost [6]. Hong Kong is facing similar problems. Sui- Such a build-up of family and kin relationships is cide is now the leading cause of death among females based on the concept of filial piety (Chinese tradition aged 15–24 years in Hong Kong [19], where suicide of xiao). Filial piety serves as a guiding principle has steadily climbed up to the sixth most common governing the general Chinese pattern of socialization cause of deaths [20]. and rules of intergenerational conduct across the life- Unlike Western data on suicide, where males are at span [28]. Chinese elders depend upon younger gen- higher risk of suicide than females, the gender ratio erations for both emotional and instrumental support. appears roughly similar in China and Hong Kong [21]. Yet filial piety also requires younger generations to In China both young and elderly women are at higher honour and obey elders [29]. In return, elders give risk, and rural women at greater risk than urban advice, comfort, teaching and help to others in need. women [22,23]). The exact cause of the higher risk Hence, elders have a meaningful role in both family in females is not clear, but sex inequalities, social and society [30]. Filial piety therefore serves as an adversity for females and deaths associated with important value of enhancing social integration and pesticides in impulsive suicidal attempts have all been cohesion in the traditional Chinese community. proposed as possible causes [23]. In one study, unem- Durkheim’s classic theory proposed that there is a ployment, receipt of disability pension, low income negative association between social cohesion and and low wealth status were associated with higher suicide [31]. From this, the change in socioeconomic risks of suicide [24,25]. A recent study in Hong Kong and political structure might account for changes in found that the socioeconomic adversity in Hong Kong suicide rates in many countries [21]. Studies in the from 1997 to 2006 was paralleled by a 50% increase in West on regional variations in suicide have consis- the suicide rate from 12.1 per 100 000 in 1997 to 18.6 tently found that districts characterized by markers per 100 000 in 2003 [26]. A recent psychological of low social integration – such as the proportion of autopsy study conducted in Hong Kong found that single-person households, divorced people and popu- unemployment and indebtedness were significant lation mobility in an area – have the highest rate of risk factors for suicide, especially among young suicide [32–34]. males [27].

EAST MEETS WEST: CURRENT MENTAL HEALTH BURDENS IN GREATER CHINA 521 The traditional values of Chinese culture have Another possible mechanism by which cultural suffered a substantial blow in the last 50 years, with values protect against suicide may be related to fervent attacks on traditional Chinese values during the life-preserving beliefs of Chinese culture. The the Cultural Revolution (1966–1976), followed by the Chinese cultural belief of filial piety, which empha- recent introduction of Western cultural ideals conco- sizes social responsibility to families and to the com- mitant with market reforms and the open-door policy munity at large, equates suicidewith casting a curse on (1978 to the present). Is there any evidence to suggest to one’s parents (shenti fahu shouzhu fumu) and, as a rise in suicide rates in the last 50 years? Reliable data such, may provide a strong moral objection against were only available in the 1970s, when epidemiolo- suicide. Is there any evidence that such life-preserving gical studies were initiated throughout China. The values of Chinese culture protect against suicide? In Twelve Region Chinese Epidemiological Survey of a community study of Hong Kong adolescents, tradi- Mental Disorders was conducted by Chinese psychia- tional values like obedience and respect for elders trists with the assistance of the Mental Health Pro- were protective against suicidality for girls but not for grams at the World Health Organization in 1982 [2]. boys. Endorsement for self-direction was correlated The study suggested that a several-fold increase in with reduced suicide rates for boys but not for suicide rates had occurred over the preceding dec- girls [19]. A recent population-based epidemiological ade [2]. Apart from the observation of longitudinal survey of adults aged 20–59 (N ¼ 2015) in Hong Kong change in suicide rates, recent high-quality cross- has found that when respondents’ reason for living sectional epidemiological studies conducted in differ- scores were high (defined as one standard deviation ent regions have also highlighted the importance of above the mean), mean life distress levels were not social cohesion as a risk factor of suicide. In a recent associated with the probability of past-year suicidal national case-control psychological autopsy study in ideation, whereas for respondents’ with a low reason China (N ¼ 1015), for example, high levels of depres- for living scores (defined as one standard deviation sive symptoms, acute stress at times of suicide, high below the mean), the probability of having suicidal chronic stress and severe interpersonal conflicts ideation increased substantially with the mean life before suicide were all significant predictors of sui- distress scores [37]. Such findings provide some pre- cide [18]. In a recent community study of 1000 elderly liminary evidence that social cohesion, cognitive people in Taiwan, suicidal ideation was associated appraisal of meaning of life and religious affiliation with depression, low level of education and lack of may be closely related. community participation and integration [35]. Again, Apart from the possible impact of changes in low levels of acculturation and social assimilation cultural values on mental health, the introduction of were identified as risk factors for suicide among native a market economy, clashes between old and new Taiwanese [36]. Poor social support, being single or institutional policies, as well as the percolation of the divorced, and lack of social cohesion were similarly Western concept of ‘free competition’ into all facets identified as significant predictors of suicide in a of life (employment, education, promotion and career recent territory-wide case-control psychological opportunities) may all lead to increased psychological autopsy study in Hong Kong [27]. stress and increased incidence of mental disorders. 39.4 DEPRESSION: IS IT LESS COMMON IN THE CHINESE POPULATION? Depression appears to be less prevalent in Asian and the United States, were significantly higher (17.1 regions (e.g. Japan, Taiwan and Mainland China) than and 6.4%, respectively) (see Reference [41] for a inWesternsocieties[38–40].TheWHOstudyreported review). A recent epidemiological study in Beijing that the prevalence of depression in primary care also found a lower point prevalence of depression settings was 2.4% in China, whereas the prevalence (3.3% inBeijing)[42].Afurther similarstudyinHebei ratesinWesterncountries,suchastheUnitedKingdom province reported a point prevalence of 2.7% and

522 GLOBAL MENTAL HEALTH a lifetime prevalence of 4.75% [43]. Although there is Chinese to mean ‘neurological weakness’ (shenjing some regional variation in the prevalence and shuairuo – these words translate as weakness of the incidence of depression, these recent studies have channels carrying vital energy, or qi, through the consistently suggested that depression is less common body [53]). Neurasthenia became widely used by in China. psychiatrists in China, who viewed it as a state of illness determined by dynamic interactions between inherited vulnerability to neurosis and environmental 39.4.1 Under-recognition of depression stress [54]. This concept of nervous system disorder in the Chinese population? and its view on disharmony of vital organs and energy fit well with the traditional Chinese concept of illness One possible explanation is reluctance to report as an imbalance of yin and yang (the balance of the psychiatric problems. Parker et al. [44,45] have sug- positive and negative forces in the body, which is gested that the stigma of ‘insanity’, imputations of essential for the normal functions of the vital fluids ‘weakness of character’, family shame and the view and visceral systems, including the vital energy cir- that emotional illness is ‘part of life’ could explain culation), caused by external pathogens like cold or such reluctance to disclose emotional distress. damp weather [55]. Neurasthenia is therefore under- Furthermore, verbal expressions of emotional distress standably a nonstigmatizing diagnosis that is concep- are not sanctioned in Chinese culture. Emotional tually distant from a psychiatric label. Both patients messages are conveyed not in words that designate and psychiatrists prefer such a label to the psychiatric emotions but rather through metaphors that are often label of depression [1]. By the 1980s, as many as 80% related to the physical body [46]. Symbols, gestures of psychiatric outpatients in China were diagnosed as and metaphors constitute a language of emotions primarily ‘neurasthenic’ [56]. However, in the past (‘heartache’ conveys sadness, while ‘fatigue’ and decade, mainland Chinese psychiatrists have increas- ‘tiredness’ means hurt and despair) [47]. This second ingly endorsed the concept of depression and reduced explanation of disguised depression in the form of the use of the diagnostic label of neurasthenia. It is somatic complaints (‘somatization’) has been con- anticipated that alternative explanations would firmed in many studies. In a study of psychiatric become an increasingly less plausible explanation of outpatients in Singapore, Chinese patients suffering a lower prevalence of depression in the coming from depression or anxiety were more likely to report years [57]. ‘general discomfort’ and ‘pain’ than ‘anxiety’ or ‘depression’ as their chief presenting complaints [48]. A person is expected to avoid bringing personal 39.4.2 Possible reasons for the lower problems to the attention of others because such an prevalence of depression: act can undermine harmony or make inappropriate demands on the social group [49]. Studies have also protective value of cultural found that outpatients typically complain initially of factors? physical discomfort such as insomnia or muscle pain, but on further exploration usually identify emotional Alternatively, the reported lower prevalence of and social problems [50,51]. depression may reflect alower incidence of depression This idiomatic reporting of emotional distress is in the Chinese population. Community surveys under- related to another possible explanation for lower rates taken in mainland China [4,58] estimated around a 2% of depression: an alternative presentation of depres- one-year incidence rate for unipolar depression, com- sion, i.e. neurasthenia. The term ‘neurasthenia’ was pared with an annual incidence rate of 10.3% for derived from the Greek, which means a ‘lack of nerve major depression found in the United States National strength’ or ‘exhaustion of the nervous system’ [52]. Comorbidity Survey [59]. Why would there be a lower The concept of neurasthenia was introduced to China risk of depression in the Chinese population? One in early 1900 and was commonly understood by the putative protective factor is the positive value of

EAST MEETS WEST: CURRENT MENTAL HEALTH BURDENS IN GREATER CHINA 523 Chinese culture. A recent cross-sectional study on which a person can reduce the negative impact of a large representative sample of Chinese elders stress [63]. Perceived and received support from close (N ¼ 1502) living in new towns in mainland China others, like family members, are especially benefi- found a negative association between adherence to cial [64]. Social relationships provide social support, Chinese tradition (adherence to traditional beliefs, give access to coping resources and give meaning to relationships and values) and level of depression [60]. life [65]. Social integration buffers stressors and con- The study also found a higher level of depression tributes to more positive mental health [66]. Recent (17.9%) among those living in newly developed towns studies in Hong Kong have indeed confirmed lower transitioned from rural farms and villages (compared levels of filial piety in depressed outpatients compared with a pooled prevalence of 14.8% in a meta-analysis with normal controls [67,68]. If the above is true, this of studies of depression in older people conducted may point to an increasing incidence of depressive in various parts of China [61]). Mjelde-Mossey disorders with urbanization and westernization in et al. [60] have explained this rise as partly due to China. Indeed, there is some evidence that depressive the loss of traditional lifestyles as families move from disorder has risen in China in the past 30 years [2]. villages or farms to high-rise apartments. Losing these In conclusion, there is some emerging evidence key aspects of life also means losing familiar ways from recent well-conducted epidemiological studies of coping, the sense of social integration and tradi- in China that there is a lower prevalence and a lower tional rituals that assist individuals through key tran- incidence of depressive disorders. Under-recognition sitions [62]. How do traditional Chinese values exert of the diagnosis by mental health professionals, reluc- protective effects? One possible mediating factor is tance to disclose depressive symptoms and the pro- the presence of enhanced social support in traditional tective value of Chinese cultural factors may explain Chinese culture. Social support is a valuable means by the important differences. 39.5 PSYCHOSES: A SERIOUS AND EMERGING PROBLEM IN CHINA Unlike Western countries, China does not have a 39.5.1 Health burden of schizophrenia national health insurance system in which mental in China health service is available to all. Some patients with severe mental disorders remain untreated, especially In a recent large-scale survey in Beijing involving in rural areas of China, possibly due to economic more than 5900 subjects in both rural and urban reasons [69]. Furthermore, lack of understanding regions, the lifetime prevalence of schizophrenia, as about severe mental disorders among relatives and defined by the Composite International Diagnostic health professionals may reduce the chances of early Interview, was 0.49% [72], which is roughly similar detection and intervention [70]. Phillips et al. [71] to figures reported in the West. Furthermore, in the found that relatives of patients suffering from schi- Xiang et al. [72] study, 9.7% of subjects with lifetime zophrenia attributed the causes of schizophrenia schizophrenia had attempted suicide at least once. mainly to social, interpersonal and psychological The striking finding is that only 58% of those with difficulties. Family members in urban regions tended schizophrenia were currently receiving treatment. In to attribute the illness to personality problems in the concordance with the discussions on stigma and patients, while rural family members tended to attri- understandings of mental illness above, only 29% of bute the illness to mystical or spiritual forces. Chi- these subjects preferred seeking treatment from men- nese families also tend to regard having a family tal health professionals. What is worrying is that never member who suffers from a severe mental disorder as receiving treatment may increase mortality [73] – the highly shameful. There is a high level of stigma and standardized mortality ratio (SMR) of a recent large- mentally ill patients are often targets of ridicule and scale 10-year cohort follow-up study of patients suf- fear [10]. fering from schizophrenia revealed very high ratios of

524 GLOBAL MENTAL HEALTH death due to suicide (SMR ¼ 94.5 for the 15–40 years still used commonly as a first-line treatment for schi- group) and of death due to other causes (SMR ¼ 10.2 zophrenia and other associated conditions like mania for the 15–40 years group). These ratios were much or treatment-resistant depression in rural and some higher than in other developed countries [74]. This undeveloped provinces. The incidence of leucopenia suggests an urgent need for public policy initiatives was 3.92% and agranulocytosis was 0.21%; around to promote understanding of severe mental disorders one-third of reported cases with agranulocytosis and reduce stigma [5]. died (around 7 deaths in every 10 000 patients exposed) [76]. This is much higher than the reported mortality rate associated with clozapine in the UK 39.5.2 Treatment interventions in China (risk of death from agranulocytosis is less than 1 in for schizophrenia 10 000 patients exposed; Novartis reported 4 deaths from 47 000 exposed, as reported in Taylor et al. [77]). Another major problem associated with the treatment There is a pressing need to educate medical profes- of psychosis in China is related to patterns of pre- sionals in rural areas to restrict the prescription of scribing. For those hospitalized patients receiving clozapine to treatment-resistant schizophrenia and to antipsychotic medication, many were either receiving enhance blood monitoring mechanisms for patients. conventional antipsychotics or clozapine while sec- Although there is some encouraging sound evidence ond-generation antipsychotics were less commonly of use of psychosocial interventions (social skills used [75]. Another descriptive study based on a training, symptoms self-monitoring, and medica- literature search of Medline and the China National tion self-management) for schizophrenia in China Knowledge Infrastructure Database (1979–2007) has (module-based psychosocial interventions reported confirmed that 26–60% of all treated patients with by Xiang et al. [78] and lifestyle interventions for schizophrenia were receiving clozapine, a situation antipsychotic-induced weight gain by Wu et al. [79]), that is drastically different from Western countries. the provision of such psychological interven- Although clozapine has now been recommended in tions remains restricted to top-tier centres. Similar the management guideline of treatment of schizophre- encouraging studies on psychosocial interventions nia as a second-line drug [76], one possible reason for for schizophrenia are also developing in Hong such high levels of clozapine prescribing is that it is Kong [80–82]. 39.6 ADDICTION: A MAJOR PUBLIC HEALTH ISSUE IN MODERN CHINA 39.6.1 Illicit drug abuse level [87]. Furthermore, there has been a steady rise in the use of amphetamine stimulants and ketamine, Before the founding of the People’s Republic of China especially among the young [88]. Many drug abusers in 1949, it was estimated that there were more than 20 are also at high risk of contracting HIV, due to million opiate abusers in the country, representing associated high-risk behaviours (e.g. unprotected around 5% of the population [83]. Due to a determined sexual behaviour and practice of prostitution [89]). crackdown in the early 1950s, drug abuse was then However, there is a heavy social stigma towards drug considered to be rare in China [84]. However, with the abusers, both in public and among health profes- development of a market economy during the 1980s, sionals [90]. Such discrimination reduces the acces- China has experienced a rapid rise in drug use, pre- sibility of treatments for drug abusers and creates a dominantly heroin abuse. It has been estimated that vicious cycle of social marginalization and continued there are around 1.16 million drug addicts in China, abuse. Furthermore, current interventions for drug of which 75–85% of them are dependent on her- abuse mainly focus on acute treatments with very oin [85,86]. The majority of heroin addicts are young, limited availability of psychosocial treatments [91]. single, unemployed males with a low education There is an urgent need to address stigmatization, to

EAST MEETS WEST: CURRENT MENTAL HEALTH BURDENS IN GREATER CHINA 525 train up more professionals in addiction psychiatry, more than women and heavy drinkers constituted to incorporate more psychosocial elements into cur- 6.7% of the sample but 5.5% of all alcohol consump- rent treatment interventions for substance abusers, tion. A six-centre survey conducted in China in 1994 and to establish a national intergovernmental office (N ¼ 23 513) has also found a fourfold increase in with special responsibilities for the treatment of drug alcohol-related admissions to psychiatric hospitals addiction [91]. between 1980 and 1993. The prevalence of current alcohol dependence was 6.6% in men and 0.1% in women [96]. The prevalence of alcohol dependence 39.6.2 Alcohol abuse had an inverse U-shaped association with family income (i.e. individuals with low or high income had Alcohol abuse is a further serious public health pro- a relatively low rate of alcohol dependence). Nation- blem in modern China. Alcohol is part of many wide surveys covering 12 regions (N ¼ 12 000 house- traditional festivals and celebrations, and is asso- holds involving 38 136 persons) conducted ten years ciated with the arts and poetry, even medicine [92]. apart revealed a 40-fold increase (from 0.02% in 1986 A wide range of alcoholic beverages are consumed in to 0.68% in 1993) in the prevalence of ICD-9 defined China, ranging from strong distilled liquor (over 50% alcohol dependence [97,98]. Multiple physical, psy- ethanol) to rice wine (12–18% ethanol). The free- chiatric and social complications have been found in market economy since 1978 has provided a new and patients with alcohol dependence in China [99,100]. ever-expanding market for alcohol. The rate of com- Current treatments of alcohol-related problems in mercial production has increased sixfold from 0.4 kg China are mainly inpatient based and are expensive per person in 1952 to over 2.5 kg by the end of 1978. (hence not accessible to people without health insur- The rate of growth continued up to 22.9 kg per person ance) [92]. A variety of interventions for alcohol in 1997 and further to 43 kg per person in 2005 [93]. dependence (medication like naltrexone, traditional A 2001 World Health Organization (WHO) spon- Chinese Medicine, acupuncture and aversion therapy) sored survey of 25 000 subjects in five centres in China have been described in case reports [101]. More showed an annual ethanol consumption of 4.5 litres rigorous high-quality trials are needed to assess the among adults aged 15 years or older (see Refer- effectiveness of these interventions in the treatment ence [94] for details on the findings in China). This of alcohol-related disorders in China. The use of self- was low compared with other industrialized countries help organizations like Alcoholics Anonymous is in the West (8.6 litres per person) [95]. Men drank restricted to a few centres in China. 39.7 MENTAL HEALTH OF MIGRANT WORKERS IN CHINA: A NO-MAN'S LAND FOR EVERYONE? Migration is a very stress-inducing phenomenon and As social welfare benefits are closely linked to resi- has been associated with various psychiatric disor- dential status in the Household Registration System, ders [102]. According to the Gazette of the State migrant workers are excluded from social security and Councilof thePeople’sRepublicof China, thenumber medicalbenefitsinthecities.Arecentsurveyhasfound of migrant workers in the major cities of China that only 14% of migrant workers had health insur- exceeded98millionin2003[103].Mostofthemigrant ance, compared with 79% of local employees in the workers come from central and western parts of same city [105]. Due to their low work status in the China seeking work in eastern and coastal cities like cities and their nonentitlement to the subsidized rental Beijing, Shanghai and Shenzhen. As most migrant system, many migrant workers live in poor housing workersare uneducatedand unskilled, theyareusually environments [106]. They also experience discrimina- employed in physically demanding but low-wage tion and marginalization from urban residents, as they jobs in factories and construction industries [104]. are often perceived by locals as a threat to social

526 GLOBAL MENTAL HEALTH stability and as a source of crime in the cities [107]. migration itself is a complex phenomenon and the Surveys of migrant workers in both Shenzhen [108] individual migrant goes through a series of stages of and Shanghai [109] found that around 25% of male adjustment. The stresses of adjustment inevitably migrant workers and 10% of female migrant workers influence outcomes, which are further mediated by could be considered to have psychiatric problems. The age, gender, whether migration is forced or voluntary, symptoms included obsession and compulsion, hosti- and whether migrants travel alone or in groups. Indi- lity, depression and phobic anxiety. Male migrant vidual resilience and coping strategies also influence workers who were married and experienced financial outcomes. As China continues to thrive economically, and employment-related difficultieswere ata high risk migrant workers’ mental health is likely to become a of having psychiatric problems. The heavy financial more important public health issue in the more pros- and family burden on male migrant workers reflected perous cities along the coast. Their situation may be stressderivedfromthevalueplacedonworkformenin expectedtoimproveinthemediumtermasthenational Chinese society [109]. As suggested by Bhugra [102], economy develops further. 39.8 CONCLUSIONS It is apparent that China is an immense, heteroge- 3. Cooper, J. and Sartorius, N. (1996) Mental Disorders neous, rapidly changing society where peoples have in China, Gaskell, London. experienced powerful and contradictory social forces. 4. Murray, C. J. and Lopez, A. D. (1996) The Global There is increasing evidence that mental health pro- Burden of Disease: A Comprehensive Assessment of blems are on the rise in China. Over the past decade, Mortality and Disability from Diseases, Injuries, and the Chinese government has also issued a series of Risk factors in 1990 and Projected to 2020, Harvard University Press, Cambridge, Massachusetts. statements emphasizing that mental health is a top 5. Phillips, M. (2004) Mental health problems in China – health priority. There is also an encouraging trend as the challenges and choices in the 21st century (in high-quality research studies are increasingly being Chinese). Chinese Journal of Nervous and Mental funded by the government. However, how such Disease, 30, 1–10. research evidence can be translated into real-world 6. World Health Organization (WHO) (2000) The World clinical practice is a formidable problem faced by a Health Report 1999, WHO, Geneva. country with a population of over 1.3 billion people. 7. WHOWorld MentalHealth SurveyConsortium (2004) Ensuring uniformity of standards of care and of types Prevalence, severity and unmet needs for treatment of of mental health services available across rural and mental disorders in the World Health Organization urban areas is a further challenging and yet pressing World Mental Health Survey. Journal of American issue to be dealt with by the Chinese government. Medical Association, 29, 2581–2580. 8. Zhang, M. Y. (2006) Challenge to mental health ser- vices in China: thinking from World Mental Health REFERENCES Survey (in Chinese). Journal of Shanghai Jiaotong University (Medical Sciences), 26, 329–334. 1. Kleinman, A. (1986) Social Origins of Disease 9. World Health Organization (WHO) (2005) Mental and Distress: Depression, Neurasthenia and Pain in Health Atlas. The Mental Health: Evidence and Modern China, Yale University Press, New Haven, Research Team (MER), WHO, Geneva. http://www. Connecticut. who.int/mental_health/evidence/atlas. 2. Shen, Y. C., Chen, C. H. and Zhang, W. X. (1986) An 10. Sun, X. L. (2007) Mental health service in general epidemiological investigation on mental disorders in hospitals in China (in Chinese). Journal of Evidence– 12 regions of China. Methodology and data analysis Based Medicine, 7, 555–556. (in Chinese). Chinese Journal of Neurology and Psy- 11. Phillips, M. (1993) Strategies used by Chinese families chiatry, 19, 65–69. in coping with schizophrenia, in Chinese Families in

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40 Social psychiatry in India R. Thara and R. Padmavati Schizophrenia Research Foundation (SCARF), Chennai, India 40.1 INTRODUCTION This chapter provides a selective overview of key the focus of considerable concern, especially those issues in the social psychiatry of India. We deal in among farmers and younger people, and we discuss particular with the role of families and their experi- this issue in detail. The epidemiological and social ences and burden (see also Chapter 9), with the aspects of suicide in India determine medical, psy- disabilities associated with mental disorders as they chological and social methods of intervention. Sec- exist in India and the stigma experienced by both ond,competing and contrastingexplanatory models of patients and families (see also Chapter 26). Relevant mental disorders held by the community result in research within India is cited and discussed with varied patters of helpseeking behaviour. This has been reference to the sociocultural context. Two further studied in some detail in India and we introduce key topics are addressed. First, suicides in India have been issues and findings. 40.2 FAMILY CARE AND BURDEN In India, it is an established fact that over 90% of the One of earliest studies on this subject was the mea- severe and chronic mentally ill live with their surementofexpressedemotion(EE)inanIndiansample families [1]. Families are involved in all parts of the and its comparison with data from the West. This was decision-making process regarding treatment, such as part of the WHO Determinants of Outcome project. It whento initiate treatment, where to go and how long to was found that EE in Indian families was lower than in continue treatment. They are also primarily respon- Londonfamilies.Theinferencefrequentlydrawnisthat sible for the continued care of the patients in the thismay,inpartatleast,accountforthe betteroutcomes community and for ensuring adherence to treatment. for schizophrenia often observed in India [2]. This section will deal with family attitudes, burden Several scales on attitudes and burden have been and coping in Indian families. developed in India. Some of them are the Family Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

532 GLOBAL MENTAL HEALTH Burden Scale of Reference [3] and the Burden Assess- disorder [8]. Gururaj et al. [9] compared the burden ment Scale (BAS) developed by the Schizophrenia and quality of life in families of persons with schizo- Research Foundation (SCARF), which measures both phrenia and OCD and did not find significant differ- subjective and objective burden [4]. The financial ences, underscoring the need to also initiate structured burden of severe mental disorders is high in India. programmes for families of persons with OCD. The While state-run hospitals provide free treatment and WHO Collaborative Study on Strategies for Extend- medicines, they are few in number and exist only in ing Mental Health Care [10] screened 259 families in urban areas. Besides, the middle and higher socio- four developing countries (Colombia, India, Sudan economic groups are not particularly comfortable and the Philippines) for the social burden caused by using these services.Tocompound the problem, medical mental illness in a family member. Levels of subsis- insurance schemes do not include mental health care and tence, previous illness, financial burden, personal hence families largely bear the costs of illness – both relations and social acceptance were studied. The direct and indirect. social burden was found to be greatest in the urban Attempts have been made to correlate burden with areas. functioning of patients. Loganathan and Murthy [5] in With the breaking up of joint families, more nuclear 2008 assessed functioning in 100 patients with schizo- families and more working women, families are phrenia and the burden and methods of coping of their increasingly seeking professional help to cope primary caregivers, all of whom were family members. with mentally ill members of the family. This has Fatalism and problem solving were the two most therefore resulted in well-structured family interven- preferred ways of coping. Problem-focused coping, tion programmes in some centres, especially aca- i.e. problem solving and expressive action, decreased demic settings with better resources. Family educa- the burden of caregivers, while emotion-focused cop- tion is a major component of this process and has ing, i.e. fatalism and passivity, increased it. As the level been studied in some detail. Kulhara et al. [11] con- of functioning of the patient decreased, the coping ducted a randomized controlled trial of family strategies seemed to increase. The use of problem- psychoeducation for both patients and families. solving coping by caregivers showed a significant Structured psychoeducational intervention was sig- correlation with higher-level functioning in patients. nificantly better than routine outpatient care on several Rammohan et al. [6] found that families of persons indices, including psychopathology, disability, care- with schizophrenia used denial and problem-solving giver support and caregiver satisfaction. The psychoe- strategies. The strength of religious belief and per- ducational intervention package used was simple, ceived burden were significant predictors of the well- feasible and inexpensive and the authors recommend being of carers. From this, the authors emphasized the it as a routine, viable facet of intervention for schizo- need to reinforce religious coping methods as a com- phrenia in India. ponent of family intervention programmes in India. A Finally, an important offshoot of family involve- study of untreated or irregularly treated patients in a ment in the process of care has been the formation and rural community by Murthy et al. [7] further showed a maintenance of family support groups in the last reduction of burden on the family and better function- decade. They consider themselves as micro-organiza- ing of the patients with the onset of regular treatment. tions demonstrating the virtues of ‘small is powerful’ Family burden is not confined to schizophrenia – it and advocating family empowerment as the core of is also felt by carers of persons with dysthymia, emotional strength and support to those with a obsessive-compulsive disorder (OCD) and bipolar disorder [12]. 40.3 DISABILITY Although the disability associated with mental illness disabilities through the Indian Persons with Disabil- has been recognized and placed on a par with other ities Act 1996, very little is happening on the ground.