WHO conference: Mental health services - development challenges on all fronts
Helsinki 13 Jan: Mental health service development has undergone a long haul from institutional-based care centred on high ratios of hospital beds per population to diverse forms of community care. But how do mental health professionals and experts evaluate the quality and effectiveness of services at a time when mental health care is in need of greater across the board support?
A session on the needs of mental health services held at the WHO European Ministerial Conference on Mental Health looked at the ideals and discourses on providing high quality, flexible and comprehensive services as well as the realities in the form of problems and challenges that still need to be tackled.
One of the main challenges in developing community based mental health services is that they ought to be ‘seamless’ - composed as a mosaic of elements that work in unison, according to Dr John Henderson, UK senior policy advisor.
Henderson said that the process of deinstitutionalisation of mental health care, coupled with the decentralisation in health services as a whole, led to the transition towards the community-based care in dealing with mental health. The process has been pretty much the same in all industrialised countries.
The session looked at the many disjunctions between the various elements of mental health care services as community-based initiatives have taken over. Henderson said that the various elements of community services need to be integrated. “And they have got to be based on the needs of individuals, covering wellbeing, housing, social support and employment.”
Stakeholders - such as family carers, NGOs, employers, schools, the justice system - need to be given more emphasis among mental health care professionals, Henderson stressed. “Health care professionals perhaps adopt a paternalistic approach to stakeholders. Maybe mental health is too important an issue to be left to psychiatrists alone.”
He said that the new policy paradigm concerning public mental health is a commitment to creating mentally healthy societies, “not just for mental health patients but for everyone”. It also means an effort to improve the mental health of the population and involves an understanding of risks and preventative measures.
Professor Toma Tomov of the Sofia Medical Academy, Bulgaria, also outlined the characteristics of what should comprise developed mental health care. “It should be a network of services offering individual treatment, occupation through gainful employment, accommodation in one’s own living space, and social support involving personal social networks.”
Striking a balance
Professor Graham Thornicroft of the Institute of Psychiatry in London stressed that the transition from mental health services weighted on inpatient institutionalisation toward community based care is not an either-or process, but should aim for a balance. “Balanced care means both hospital and community services,” he said. “The evidence is clear: we can no longer have a debate about hospital or community care - we need a balance of both.”
Thornicroft said that combating the stigma attached to mental ill health is a crucial problem. The idea that people who are mentally ill are dangerous doesn’t match up homicide statistics, “despite what we are told by the popular press.”
“The huge task ahead of us is to find out what works in reducing discrimination against people with mental health problems.”
Stigma not tackled enough
Inger Nilsson of the European Federation of Associations of Families of People with mental Illness also targeted the problems of stigma and discrimination. Looking at the situation of family carers - who are the main care providers of people suffering mental ill health - Nilsson said that stigma often forced families into secrecy and denial.
“Anti-stigma campaigns have been promoted in many countries but much more needs to be done. There is still a popular misconception of a link between mental illness and violence in society.”
Nilsson said that family carers want to be included in all aspects of the care process, and that when families are properly involved the outcome is usually better for their sick relatives.
She said that in addition to stigma and discrimination family carers face difficulties to get access to dependable mental health services and to attain proper empowerment in their role that would include information, training, support and involvement. “There is a lack of communication between professional staff and family carers.”
Choice too often illusory
Mary Nettle of the European Network of (ex)Users and Survivors of Psychiatry took up the viewpoints of people who are on the receiving end of mental health services. “Mental health service users wish to be treated with dignity and respect,” she said.
Nettle pointed to the disparity between the ways in which mentally ill people and people with severe physical ailments are treated by health services. Accessto treatment for diseases such as cancer or heart problems is often immediate and unquestioning, she said, but attitudes towards severe mental illness are different.
She criticised conventional rhetoric about there being a range of service options in mental health care. “There is much talk about having a choice of services in areas in which people live but in mental health there is often no such choice.”
There is a pressing need to involve service users integrally, she said, and outlined ways to improve the situation. Research leading to evidence-based practice should involve service users in research rather than objectifying them.
“Service users should also be used as educators and trainers. They should be involved in the recruitment of staff at all levels - this can work. But such involvement cannot happen on a voluntary basis: service users have to be rewarded for their work.”