A dichotomous approach to Mental Health

Héðinn UnnsteinssonMental Health Policy expert with the Icelandic Ministry of

Health Former Technical Officer with MH Programme of WHO-

EURO

2

WHO am I?• Héðinn Unnsteinsson

– First experience of manic-depression during medical studies in 1991

– Held in hospital, diagnosed and medicated in 1994

– Advocate and a lobbist in a user NGO from 1995-

– Graduated with two University degrees in education in 1996 & 1999

– Started the icelandic mental health promotion project (Geðrækt) in 2000 and ran it until 2002

– Graduated with a M.Sc in International Policy Analysis from the Univ. of Bath in 2003

– Internship with WHO HQ in 2003– Technical Officer with the MH program of

WHO-EURO since march 2004-jan 2007– Part time lecturer with the Public Health

Dep of the University of Reykjavik and with the PHD of the University of Iceland

– A mental health policy expert with the Icelandic Ministry of Health

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Set up

1. The duality & conceptuality of mental health

2. The burden of mental health problems3. The Helsinki documents4. Trends of change; users in Europe and

the Transformation Process 5. The Horizontal ideology6. Inclusion of Civil Society (ICS)7. Conclusion in Norway

The duality & conceptuality of mental health/mental ill

health

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Conceptuality Historical Madness becomes a mental health

problem

• Madness -> Mental illness -> Mental health problem

• Dichotomy & Dualism– Hygieia (social, causal)– Asclepius (medical,

consequential)

• Ship of fools– Foucault

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Mad-his-Story• Quakers in Philadelphia 1840-70

– Empathy, compassion, humanism• Social Eugenics 1920-1940

– Francis Galton• ‘Kantian’ science of mental illness 1900-

– somatic and psychotropic emphasis – Insulin coma– Electroshocks– Frontal-Lobotomy– Sterilisations – Closed wards-forced treatment– Neuroleptic drugs (Thaorazine,

Haldol)– SSRI antidepressant

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The dichotomy of health in modern times

HYGIEA VS. ASCLEPIUSA social approach to

health aims to preserve health by considering the

way of life, while the medical approach restores health by treatment of dis-

ease (McKeowan, 1979)

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The Medical Model

The Social Model

‘Dis-ease’ ‘Ease’

Asclepius Hygieia

Medicalisation Health Promotion

Natural science Social Science

Mental ill health Mental health

Individual Collective

12Héðinn Unnsteinsson

Mynd 1.

The illness system The health system Illness Health

Rehabilitation

Treatment

Early Intervention

Prevention

Promotion

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Lessons from history

• “ As we in the 21st century

shake our heads over the

methods that were used to

“cure” mental disorders 50-100

years ago; as will our children

look back and shake their

heads over some of the methods

and approaches we are using

now”

Burden of dis-ease/mental health problems

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“Burden” of dis-ease

• “Burden” caused by psychiatric- and neurological diseases:– 19.5% in Europe/ 13% in the

World (DALY’s) (disibility adjusted life years)

– Cause of 39.7% of all disability in Europe (YLD) (Years lost to disability)

– Estimated that 27% of all Europeans suffer at any given time from a mental health problem (EU green paper, 2006)

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Burden of disease

CAUSES DALYs %

1. Ischemic heart disease 12.5

2. Unipolar depressive disorders 5.9

3. Cerebrovascular disease 5.5

4. Self-inflicted injuries 4.9

5. Road-traffic accidents 3.1

6. Alcohol-use disorders 2.9

7. Hearing loss, adult onset 2.9

8. Osteoarthritis 2.5

9. Violence 2.3

10. Trachea, bronchus and lung cancer 2.0

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Neuro-psychiatric conditions Europe: Years lost to disability

Ranking 1st

Unipolar depressive disorders 13.7%

Ranking 2nd

Alcohol use disorders 6.2%

Ranking 7th

Alzheimer and other dementias

3.7%

Ranking 11th

Schizophrenia 2.3%

Ranking 12th

Bipolar disorders 2.2%

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Total health budget

Mental health budget

Total DALYs

Neuropsychiatricconditions

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Treatment Gap Western Europe

• Psychosis: 17.8%

• Bipolar disorder: 39.9%

• Major depression: 45.4%

• Panic disorder: 47.2%

• Anxiety disorder: 62.3%

• Alcohol dependence: 92.4%

Kohn 2004

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The Helsinki documents The Helsinki Documents

The WHO/EURO 2005 Mental Health Declartion and Action Plan for Europe

http://www.euro.who.int/mentalhealth

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Pre• Who contributed:

– WHO/EURO– European Commission (Commissioner

of Health and Consumer Protection)– Council of Europe (CoE)

• The declaration was both a new beginning and an end in itself:– 30-40 (declarations, resolutions,

conclusions etc CoE, WHO, EU)• Wide socio-economical dualistic

approach (mh vs. mi)– “We believe that the primary aim of mental health activity

is to enhance people’s well-being and functioning by focusing on their strengths and resources, reinforcing resilience and enhancing protective external factors” (1.art form preamble of the decl.) (..Alma Ata, Ottawa etc…)

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Ministerial Conference on Mental Health in Helsinki

•400 participants

•228 country representatives from 51 Member States

•42 ministerial level

•23 NGOs present

•35 users and carers

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Priorities for the next decade

• Foster awareness of the importance of mental wellbeing;

• Empower and support people with mental health problems to tackle suffering from stigma, discrimination and inequality;

• Design and implement comprehensive, integrated and efficient mental health

systems that cover promotion, prevention, care and recovery;

• Address the need for a competent workforce, effective in all these areas.

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The Action Plan

• The 12 core action points– The challenge in every point

• With additional suggestion of actions

• The declaration is in fact the acumilated good intention of last 30-40 years

• The documents are a mental health paridigm for European Governments to shape their national mh policies

• Their utility and use is based on something that they encourage highly:

Cooperation of all concerned = “The Inclusion of Civil Society” (ICS)

“an horizontal approach”

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WHO’s 4 Core Objectives:1) Reducing stigma, promoting

mental well-being and preventing mh problems

2) Implementing policy and services delivered by a competent workforce

3) Generating and disseminating information and research

4) Advocating for user empowerment and human rights

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4) Advocating for user empowerment and human

rightsIndicators:

• The ending of inhumane and degrading treatment and care and the enactment of human rights and mental health legislation across the Region;

• An increase in level of education and employment opportunities of people with mental health problems;

• An increase in active grass roots NGOs;

• Representation of users and carers on groups responsible for planning, delivery, monitoring and inspection of mental health activities.

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Trends of (slow) change; users in Europe and the Transformation Process

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Key issues of Users

• Acceptence/Empowerment• Inclusion/Involvement

– Housing– Employment– Education– Policy

• Human Rights• Stigma-Discrimination• Inequality• Treatment & Services

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•POWER•AUTHORITY

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other key issues…..users and carers in Europe are

talking about• The right to self determination on

treatment and medication (Autonomy)• Misuse of psychiatric medication (The

link of SSRI drugs to acts of violence)• The issue of “neuroleptic” drugs• Distinction between intellectual &

Psychosocial disabilities • Cooperation on the Helsinki documents• The need and desire to be heared and

have a role• Direct payments to users and carers*

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Hospital A Human Being and a taxpayer

The STATE or Municipalities

PP PP

Other Market services

Direct Payment

PP

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From Institution to Community Care

• Diversity in the community (praised in speach, neglegted in action)– No research has shown that Hospital care

alone or community care alone is sufficent– All research promote: Balance of community

and hospital care• Proportion and nature is determinated by

many factors:– The type of society, culture, methodology, – User influence, ideology etc., “social firms”

– Our big Institutions have to change.....• “the biggest institution is usually within ourself”

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20th Century Model

Hospital

Policlinics

Primary CarePrimary Care

Primary Care

PoliclinicsPoliclinics

PoliclinicsPoliclinicsPrimary CarePrimary Care

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Acute Hospital

Acute Hospital

CMHTsCMHTs

PrimaryCare

PrimaryCare

Secureplaces

Secureplaces

Inclusion and rehabilitation

Inclusion and rehabilitation

ResidentialCare

ResidentialCare

Service Model 21st CenturyService Model 21st Century

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Number of psychiatric beds in western Europe

0

50

100

150

200

250

300

350

400

450

Bed

s p

er

100,0

00

AustriaBelgiumDenmarkFinlandFranceGermanyGreeceIcelandIrelandItalyLuxembourgNetherlandsNorw ayPortugalSpainSw edenSw itzerlandUnited Kingdom

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Changes

• Mental health is a much broader issues than an medical one.

• If we want to affect it we have to go for mental health determinates, its causes, not merely diagnosing a mental dis-ease and putting on a remedy.

• And to do that we need a much broader approach than we are seeing now: Therefore: A paradigmal shift of Power is absolutely Vital if we are to move on a progress as societies.

The Horizontal ideology

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The concepts of a (N-G-R)PPCP

N=national; R= Regional; G= Global; PPCP0 Public, Private, Civil Partnership• The “Horizontal Approach” to mental health

Policy– Focuses on:

• The merger of the “top-down” approach» &

• The “bottom-up” approach to policy

– And brings in corporate resources to make the implementation phase happen.

– It means increasing the influence and control of civil society on mental health issues

– It is a branch of a larger tree of “Open democracy”

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The creation of a horizontal Hybrid

MARKET

Civil Society

STATE

Mental Health

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The creation of a horizontal Hybrid

MARKET Civil Society

STATE

Mental Health

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PROVISION

Public Private Civil Society

Public

FUNDING

Private

Civil

Society

Social democratic welfare regime (Nordic countries)

Conservative welfare regime (Partnership)

Services, prevention,

promotion programmes

(Partnership)

x

Liberal welfare regime

(USA/ semi-developed

countries)

Awareness raising,

services, prevention,

promotion

programmes(Partnership)

x x

Initiatives run and

financed by the grass

root movements

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Idea

Ministry of Health, Social affairs & governm

agencies

Civil Society (Mental Health ngo’s)

MH Objectives, National Health strategy

Driving force and motivation

A Collaborative National Mental Health Project implementation

Corporate resources

Inclusion of Civil Society (ICS)

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The Horizontal ideology

Inclusion of Civil Society (ICS) ALBANIA

Idea strategy Implementation

•Brief description of project:–The project is aimed at empowering users and carers organisations and facilitating their involvement in mental health policy and law development and implementation.

–WHO is thought of as a catalyst of this process, a neutral agent aiming to get both governmental officials and the national coalitions to work together on a “horizontal” level aiming to recognise their communalities rather than their differences and sharing power. That power sharing with in the realm of an open democracy approach could lead to a vast change in the national approach to mental health as well as in much more empowerment of those using the mental health system.

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Ministry of Health, Social affairs & governm

agencies

Civil Society (Mental Health Coalition of ngo’s)

MH Objectives, National Health strategy

Driving force and motivation

A Collaborative National Mental Health Project implementation

WHO

Natio

nal p

artn

er

CS partners

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A collection of European user stories

• A questionnarie based on the Helsinki Documents• Around 30 qualatavtive questions catagorised in 7

groups:– Advocay and emmpowerment– Human rights– Stigma and discrimination– Treatment and services– Social inclusion– Selfhelp and recovery– Times of changes

• Users from 11 countries • One story published on the WHO frontpage (one

every month starting October 2007)• Results published in 2008 in 4 languages and 52

contries

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Conclusion Norway• 1st. Users and actors within civil

society can and will have more to say about mh policy process and mh matters in general– Open democracy– Welfare changes– Market influence– Changing Health Systems

• 2nd. Governmental structures and IGOs do want to have more input from those that their “top-down” decisions are affecting– Power– Coalitions– The academic and professional sphere

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Conclusions Norway• 3rd. The balancing paradigmal

Power shift from providers to users and carers as well as user empowerment has started, but it is and will be a long run process.– Politics– Lobbying– Strategies– Marketing– Coalitions– Cooperation– Communalities– Power– Fighting with soft power– Human Nature

• The general Issue of improved mental health should unite us

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Final remarks

• In my oppinion the transformation in mental health is a branch on a larger tree of societical changes.

• Power from civilians to elected officials has been passed for years in our democracies. Now we want to shape it and share it.

• We should never forget the meaning of the word “minister” deriving from ancient Greece– = “minister” = the servant of the people

• Therefore in our “welfare” States are our mental health professionals are the servants of our elected servants.

• It is hard to serve

62Héðinn Unnsteinsson