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Prevention is currently a very small part of the spend of mental health systems. For instance the 2009 UK Department of Health analysis of prevention expenditure does not include any apparent spend on mental health.[103] The situation is the same in research.[37] However prevention is beginning to appear in mental health strategies: In 2014 the UK Chief Medical Officer chose mental health for her major annual report, and included prevention of mental illness heavily in this.[104] In 2013 the Faculty of Public Health, the UK professional body for public health professionals, produced it's 'Better Mental Health for All" resource, which aims at "the promotion of mental wellbeing and the primary prevention of mental illness".[105] In 2012, Mind, the UK mental health NGO, included "Staying well; Support people likely to develop mental health problems, to stay well." as its first goal for 2012–16.[106] The 2011 mental health strategy of Manitoba (Canada) included intents to (i) reduce risk factors associated with mental ill-health and (ii) increase mental health promotion for both adults and children.[107] The 2011 US National Prevention Strategy included mental and emotional well-being, with recommendations including (i) better parenting and (ii) early intervention.[108] Australia's mental health plan for 2009–14 included "Prevention and Early Intervention" as priority 2.[109] The 2008 EU "Pact for Mental Health" made recommendations for youth and education including (i) promotion of parenting skills, (ii) integration of socio-emotional learning into education curricular and extracurricular activities, and (iii) early intervention throughout the educational system.[110] Prevention programmes In 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT for people at risk of psychosis.[97][111] In 2013 the UK NGO Mental Health Foundation and partners began to use Video Interaction Guidance (VIG) in an early years intervention to reduce later life mental illness.[112][113] In 2013 in Australia the National Health and Medical Research Council supported a set of parenting strategies to prevent teenagers becoming anxious or depressed.[114][115] In 2012 the UK Schizophrenia Commission recommended "a preventative strategy for psychosis including promoting protective factors for mental wellbeing and reducing risks such as cannabis use in early adolescence."[37] In 2010 the European Union DataPrev database was launched. It states "A healthy start is crucial for mental health and wellbeing throughout life, with parenting being the single most important factor," and recommends a range of interventions.[116] In 2009 the US National Academies publication on preventing mental, emotional, and behavioral disorders among young people focused on recent research and program experience and stated that "A number of promotion and prevention programs are now available that should be considered for broad implementation."[117][118] A 2011 review of this by the authors said "A scientific base of evidence shows that we can prevent many mental, emotional, and behavioral disorders before they begin" and made recommendations including supporting the mental health and parenting skills of parents, encouraging the developmental competencies of children and using preventive strategies particularly for children at risk (such as children of parents with mental illness, or with family stresses such as divorce or job loss).[119] In India the 1982 National Mental health Programme included prevention,[120] but implementation has been slow, particularly of prevention elements.[121][122][123] It is already known that home visiting programs for pregnant women and parents of young children can produce replicable effects on children's general health and development in a variety of community settings.[124] Similarly positive benefits from social and emotional education are well proven.[125] Research has shown that risk assessment and behavioral interventions in pediatric clinics reduced abuse and neglect outcomes for young children.[126] Early childhood home visitation also reduced abuse and neglect, but results were inconsistent.[127] Assessing parenting capability has been raised in child protection and other contexts.[128][129][130][131] Delaying of potential very young pregnancies could lead to better mental health causal risk factors such as improved parenting skills and more stable homes,[132] and various approaches have been used to encourage such behaviour change.[133][134][134][135][136] Some countries run conditional cash transfer welfare programs where payment is conditional on behaviour of the recipients. Compulsory contraception has been used to prevent future mental illness.[137] Prevention programs can face issues in (i) ownership, because health systems are typically targeted at current suffering, and (ii) funding, because program benefits come on longer timescales than the normal political and management cycle.[138][139] Assembling collaborations of interested bodies appears to be an effective model for achieving sustained commitment and funding.[140] Risk assessment Screening questionnaires for assessing the risks of developing a mental disorder face the problem of low specificity, which means that the majority of the people with an increased risk will not develop the disorder. However combining risk factors gives higher estimated risk. For instance risk of depression is higher for a widow who also has an illness and lives alone.[64] Targeted vs universal programs There has been an historical trend among public health professionals to consider targeted programmes. However identification of high risk groups can increase stigma, in turn meaning that the targeted people do not engage. Thus current policy recommends universal programs, with resources within such programs weighted towards high risk groups.[141] Management Main articles: Treatment of mental disorders, Services for mental disorders and Mental health professional „Haus Tornow am See“ (former manor house) in Tornow (Pritzhagen) (de), Germany. The former demesme with a manor house from 1912 is today separated into a special education school („Schule am Tornowsee“) and a hotel with integrated work/job- and rehabilitation-training for people with mental disorders („Haus Tornow am See“). Tornow is situated at the northern bank of the Große Tornowsee (lake) (de) Treatment and support for mental disorders is provided in psychiatric hospitals, clinics or any of a diverse range of community mental health services. A number of professions have developed that specialize in the treatment of mental disorders. This includes the medical specialty of psychiatry (including psychiatric nursing),[142][143][144] the field of psychology known as clinical psychology,[145] and the practical application of sociology known as social work.[146] There is also a wide range of psychotherapists (including family therapy), counselors, and public health professionals. In addition, there are peer support roles where personal experience of similar issues is the primary source of expertise.[147][148][149][150] The different clinical and scientific perspectives draw on diverse fields of research and theory, and different disciplines may favor differing models, explanations and goals.[25] In some countries services are increasingly based on a recovery approach, intended to support each individual's personal journey to gain the kind of life they want, although there may also be 'therapeutic pessimism' in some areas. There are a range of different types of treatment and what is most suitable depends on the disorder and on the individual. Many things have been found to help at least some people, and a placebo effect may play a role in any intervention or medication. In a minority of cases, individuals may be treated against their will, which can cause particular difficulties depending on how it is carried out and perceived. The UK is moving towards paying mental health providers by the outcome results that their services achieve.[151][152] Psychotherapy A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of significant others as well as an individual. Some psychotherapies are based on a humanistic approach. There are a number of specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement. Medication A major option for many mental disorders is psychiatric medication and there are several main groups. Antidepressants are used for the treatment of clinical depression, as well as often for anxiety and a range of other disorders. Anxiolytics (including sedatives) are used for anxiety disorders and related problems such as insomnia. Mood stabilizers are used primarily in bipolar disorder. Antipsychotics are used for psychotic disorders, notably for positive symptoms in schizophrenia, and also increasingly for a range of other disorders. Stimulants are commonly used, notably for ADHD. Despite the different conventional names of the drug groups, there may be considerable overlap in the disorders for which they are actually indicated, and there may also be off-label use of medications. There can be problems with adverse effects of medication and adherence to them, and there is also criticism of pharmaceutical marketing and professional conflicts of interest. Other Electroconvulsive therapy (ECT) is sometimes used in severe cases when other interventions for severe intractable depression have failed. Psychosurgery is considered experimental but is advocated by certain neurologists in certain rare cases.[153][154] Counseling (professional) and co-counseling (between peers) may be used. Psychoeducation programs may provide people with the information to understand and manage their problems. Creative therapies are sometimes used, including music therapy, art therapy or drama therapy. Lifestyle adjustments and supportive measures are often used, including peer support, self-help groups for mental health and supported housing or supported employment (including social firms). Some advocate dietary supplements.[155] Reasonable accommodations (adjustments and supports) might be put in place to help an individual cope and succeed in environments despite potential disability related to mental health problems. This could include an emotional support animal or specifically trained psychiatric service dog. Epidemiology Main article: Prevalence of mental disorders Disability-adjusted life year for neuropsychiatric conditions per 100,000 inhabitants in 2004. <2200 2200-2400 2400-2600 2600-2800 2800-3000 3000-3200 3200-3400 3400-3600 3600-3800 3800–4000 4000–4200 >4200 Mental disorders are common. World wide more than one in three people in most countries report sufficient criteria for at least one at some point in their life.[156] In the United States 46% qualifies for a mental illness at some point.[157] An ongoing survey indicates that anxiety disorders are the most common in all but one country, followed by mood disorders in all but two countries, while substance disorders and impulse-control disorders were consistently less prevalent.[158] Rates varied by region.[159] A review of anxiety disorder surveys in different countries found average lifetime prevalence estimates of 16.6%, with women having higher rates on average.[160] A review of mood disorder surveys in different countries found lifetime rates of 6.7% for major depressive disorder (higher in some studies, and in women) and 0.8% for Bipolar I disorder.[161] In the United States the frequency of disorder is: anxiety disorder (28.8%), mood disorder (20.8%), impulse-control disorder (24.8%) or substance use disorder (14.6%).[157][162][163] A 2004 cross-Europe study found that approximately one in four people reported meeting criteria at some point in their life for at least one of the DSM-IV disorders assessed, which included mood disorders (13.9%), anxiety disorders (13.6%) or alcohol disorder (5.2%). Approximately one in ten met criteria within a 12-month period. Women and younger people of either gender showed more cases of disorder.[164] A 2005 review of surveys in 16 European countries found that 27% of adult Europeans are affected by at least one mental disorder in a 12 month period.[165] An international review of studies on the prevalence of schizophrenia found an average (median) figure of 0.4% for lifetime prevalence; it was consistently lower in poorer countries.[166] Studies of the prevalence of personality disorders (PDs) have been fewer and smaller-scale, but one broad Norwegian survey found a five-year prevalence of almost 1 in 7 (13.4%). Rates for specific disorders ranged from 0.8% to 2.8%, differing across countries, and by gender, educational level and other factors.[167] A US survey that incidentally screened for personality disorder found a rate of 14.79%.[168] Approximately 7% of a preschool pediatric sample were given a psychiatric diagnosis in one clinical study, and approximately 10% of 1- and 2-year-olds receiving developmental screening have been assessed as having significant emotional/behavioral problems based on parent and pediatrician reports.[169] While rates of psychological disorders are often the same for men and women, women tend to have a higher rate of depression. Each year 73 million women are afflicted with major depression, and suicide is ranked 7th as the cause of death for women between the ages of 20–59. Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men.[170] History Question book-new.svg This section does not cite any references or sources. Please help improve this section by adding citations to reliable sources. Unsourced material may be challenged and removed. (May 2013) Main article: History of mental disorders Early color illustration of psychiatric treatment methods Ancient civilizations Ancient civilizations described and treated a number of mental disorders. The Greeks coined terms for melancholy, hysteria and phobia and developed the humorism theory. Mental disorders were described, and treatments developed, in Persia, Arabia and in the medieval Islamic world. Europe Middle Ages Conceptions of madness in the Middle Ages in Christian Europe were a mixture of the divine, diabolical, magical and humoral, as well as more down to earth considerations. In the early modern period, some people with mental disorders may have been victims of the witch-hunts but were increasingly admitted to local workhouses and jails or sometimes to private madhouses. Many terms for mental disorder that found their way into everyday use first became popular in the 16th and 17th centuries. Eighteenth century By the end of the 17th century and into the Enlightenment, madness was increasingly seen as an organic physical phenomenon with no connection to the soul or moral responsibility. Asylum care was often harsh and treated people like wild animals, but towards the end of the 18th century a moral treatment movement gradually developed. Clear descriptions of some syndromes may be rare prior to the 19th century. Nineteenth century Industrialization and population growth led to a massive expansion of the number and size of insane asylums in every Western country in the 19th century. Numerous different classification schemes and diagnostic terms were developed by different authorities, and the term psychiatry was coined, though medical superintendents were still known as alienists. Twentieth century The turn of the 20th century saw the development of psychoanalysis, which would later come to the fore, along with Kraepelin's classification scheme. Asylum "inmates" were increasingly referred to as "patients", and asylums renamed as hospitals. Europe and the U.S. Insulin shock therapy Early in the 20th century in the United States, a mental hygiene movement developed, aiming to prevent mental disorders. Clinical psychology and social work developed as professions. World War I saw a massive increase of conditions that came to be termed "shell shock". World War II saw the development in the U.S. of a new psychiatric manual for categorizing mental disorders, which along with existing systems for collecting census and hospital statistics led to the first Diagnostic and Statistical Manual of Mental Disorders (DSM). The International Classification of Diseases (ICD) also developed a section on mental disorders. The term stress, having emerged from endocrinology work in the 1930s, was increasingly applied to mental disorders. Electroconvulsive therapy, insulin shock therapy, lobotomies and the "neuroleptic" chlorpromazine came to be used by mid-century. In the 1960s there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman who said that mental illness was merely another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science by Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.[171] Deinstitutionalization gradually occurred in the West, with isolated psychiatric hospitals being closed down in favor of community mental health services. A consumer/survivor movement gained momentum. Other kinds of psychiatric medication gradually came into use, such as "psychic energizers" (later antidepressants) and lithium. Benzodiazepines gained widespread use in the 1970s for anxiety and depression, until dependency problems curtailed their popularity. Advances in neuroscience, genetics and psychology led to new research agendas. Cognitive behavioral therapy and other psychotherapies developed. The DSM and then ICD adopted new criteria-based classifications, and the number of "official" diagnoses saw a large expansion. Through the 1990s, new SSRI-type antidepressants became some of the most widely prescribed drugs in the world, as later did antipsychotics. Also during the 1990s, a recovery approach developed. Society and culture Self.svg Different societies or cultures, even different individuals in a subculture, can disagree as to what constitutes optimal versus pathological biological and psychological functioning. Research has demonstrated that cultures vary in the relative importance placed on, for example, happiness, autonomy, or social relationships for pleasure. Likewise, the fact that a behavior pattern is valued, accepted, encouraged, or even statistically normative in a culture does not necessarily mean that it is conducive to optimal psychological functioning. People in all cultures find some behaviors bizarre or even incomprehensible. But just what they feel is bizarre or incomprehensible is ambiguous and subjective.[172] These differences in determination can become highly contentious. Religious, spiritual, or transpersonal experiences and beliefs are typically not defined as disordered, especially if widely shared, despite meeting many criteria of delusional or psychotic disorders.[173][174] Even when a belief or experience can be shown to produce distress or disability—the ordinary standard for judging mental disorders—the presence of a strong cultural basis for that belief, experience, or interpretation of experience, generally disqualifies it from counting as evidence of mental disorder. The process by which conditions and difficulties come to be defined and treated as medical conditions and problems, and thus come under the authority of doctors and other health professionals, is known as medicalization or pathologization. Movements Giorgio Antonucci Thomas Szasz Controversy has often surrounded psychiatry, and the term anti-psychiatry was coined by psychiatrist David Cooper in 1967. The anti-psychiatry message is that psychiatric treatments are ultimately more damaging than helpful to patients, and psychiatry's history involves what may now be seen as dangerous treatments.[175] Electroconvulsive therapy was one of these, which was used widely between the 1930s and 1960s. Lobotomy was another practice that was ultimately seen as too invasive and brutal. Valium and other sedatives were sometimes over-prescribed, which led to an epidemic of dependence. There was also concern about the large increase in prescribing psychiatric drugs for children. Some charismatic psychiatrists came to personify the movement against psychiatry. The most influential of these was R.D. Laing who wrote a series of best-selling books, including The Divided Self. Thomas Szasz wrote The Myth of Mental Illness. Some ex-patient groups have become militantly anti-psychiatric, often referring to themselves as "survivors".[175] Giorgio Antonucci has questioned the basis of psychiatry through his work on the dismantling of two psychiatric hospitals (in the city of Imola), carried out from 1973 to 1996. The consumer/survivor movement (also known as user/survivor movement) is made up of individuals (and organizations representing them) who are clients of mental health services or who consider themselves survivors of psychiatric interventions. Activists campaign for improved mental health services and for more involvement and empowerment within mental health services, policies and wider society.[176][177][178] Patient advocacy organizations have expanded with increasing deinstitutionalization in developed countries, working to challenge the stereotypes, stigma and exclusion associated with psychiatric conditions. There is also a carers rights movement of people who help and support people with mental health conditions, who may be relatives, and who often work in difficult and time-consuming circumstances with little acknowledgement and without pay. An anti-psychiatry movement fundamentally challenges mainstream psychiatric theory and practice, including in some cases asserting that psychiatric concepts and diagnoses of 'mental illness' are neither real nor useful.[179][180][181] Alternatively, a movement for global mental health has emerged, defined as 'the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide'.[182] Cultural bias Current diagnostic guidelines, namely the DSM and to some extent the ICD, have been criticized as having a fundamentally Euro-American outlook. Opponents argue that even when diagnostic criteria are used across different cultures, it does not mean that the underlying constructs have validity within those cultures, as even reliable application can prove only consistency, not legitimacy.[183] Advocating a more culturally sensitive approach, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.[184] Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV. Disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, revealing to Kleinman an underlying assumption that Western cultural phenomena are universal.[185] Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics. Common responses included both disappointment over the large number of documented non-Western mental disorders still left out and frustration that even those included are often misinterpreted or misrepresented.[186] Many mainstream psychiatrists are dissatisfied with the new culture-bound diagnoses, although for partly different reasons. Robert Spitzer, a lead architect of the DSM-III, has argued that adding cultural formulations was an attempt to appease cultural critics, and has stated that they lack any scientific rationale or support. Spitzer also posits that the new culture-bound diagnoses are rarely used, maintaining that the standard diagnoses apply regardless of the culture involved. In general, mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are significant only to specific symptom presentations.[183] Clinical conceptions of mental illness also overlap with personal and cultural values in the domain of morality, so much so that it is sometimes argued that separating the two is impossible without fundamentally redefining the essence of being a particular person in a society.[187] In clinical psychiatry, persistent distress and disability indicate an internal disorder requiring treatment; but in another context, that same distress and disability can be seen as an indicator of emotional struggle and the need to address social and structural problems.[188][189] This dichotomy has led some academics and clinicians to advocate a postmodernist conceptualization of mental distress and well-being.[190][191] Such approaches, along with cross-cultural and "heretical" psychologies centered on alternative cultural and ethnic and race-based identities and experiences, stand in contrast to the mainstream psychiatric community's alleged avoidance of any explicit involvement with either morality or culture.[192] In many countries there are attempts to challenge perceived prejudice against minority groups, including alleged institutional racism within psychiatric services.[193] There are also ongoing attempts to improve professional cross cultural sensitivity. Laws and policies Three quarters of countries around the world have mental health legislation. Compulsory admission to mental health facilities (also known as involuntary commitment) is a controversial topic. It can impinge on personal liberty and the right to choose, and carry the risk of abuse for political, social and other reasons; yet it can potentially prevent harm to self and others, and assist some people in attaining their right to healthcare when they may be unable to decide in their own interests.[194] All human rights oriented mental health laws require proof of the presence of a mental disorder as defined by internationally accepted standards, but the type and severity of disorder that counts can vary in different jurisdictions. The two most often utilized grounds for involuntary admission are said to be serious likelihood of immediate or imminent danger to self or others, and the need for treatment. Applications for someone to be involuntarily admitted usually come from a mental health practitioner, a family member, a close relative, or a guardian. Human-rights-oriented laws usually stipulate that independent medical practitioners or other accredited mental health practitioners must examine the patient separately and that there should be regular, time-bound review by an independent review body.[194] The individual should also have personal access to independent advocacy. In order for involuntary treatment to be administered (by force if necessary), it should be shown that an individual lacks the mental capacity for informed consent (i.e. to understand treatment information and its implications, and therefore be able to make an informed choice to either accept or refuse). Legal challenges in some areas have resulted in supreme court decisions that a person does not have to agree with a psychiatrist's characterization of the issues as constituting an "illness", nor agree with a psychiatrist's conviction in medication, but only recognize the issues and the information about treatment options.[195] Proxy consent (also known as surrogate or substituted decision-making) may be transferred to a personal representative, a family member or a legally appointed guardian. Moreover, patients may be able to make, when they are considered well, an advance directive stipulating how they wish to be treated should they be deemed to lack mental capacity in future.[194] The right to supported decision-making, where a person is helped to understand and choose treatment options before they can be declared to lack capacity, may also be included in legislation.[196] There should at the very least be shared decision-making as far as possible. Involuntary treatment laws are increasingly extended to those living in the community, for example outpatient commitment laws (known by different names) are used in New Zealand, Australia, the United Kingdom and most of the United States. The World Health Organization reports that in many instances national mental health legislation takes away the rights of persons with mental disorders rather than protecting rights, and is often outdated.[194] In 1991, the United Nations adopted the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, which established minimum human rights standards of practice in the mental health field. In 2006, the UN formally agreed the Convention on the Rights of Persons with Disabilities to protect and enhance the rights and opportunities of disabled people, including those with psychosocial disabilities.[197] The term insanity, sometimes used colloquially as a synonym for mental illness, is often used technically as a legal term. The insanity defense may be used in a legal trial (known as the mental disorder defence in some countries). |
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