A dichotomous approach to Mental Health

1. A dichotomous approach to Mental Health Héðinn Unnsteinsson Mental 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

3. Set up • The duality & conceptuality of mental health • The burden of mental health problems • The Helsinki documents • Trends of change; users in Europe and the Transformation Process • The Horizontal ideology • Inclusion of Civil Society (ICS) • Conclusion in Norway

4. The duality & conceptuality of mental health/mental ill health

5. 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

7. 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

10. The dichotomy of health in modern times HYGIEA VS. ASCLEPIUS A 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)

13. 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”

14. Burden of dis-ease/mental health problems

15. “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)

16. Burden of disease

17. Neuro-psychiatric conditions Europe: Years lost to disability

19. 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

21. The Helsinki documents The Helsinki DocumentsThe WHO/EURO 2005 Mental Health Declartion and Action Plan for Europehttp://www.euro.who.int/mentalhealth

22. 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…)

23. 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

24. 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.

25. 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”

26. WHO’s 4 Core Objectives: • Reducing stigma, promoting mental well-being and preventing mh problems • Implementing policy and services delivered by a competent workforce • Generating and disseminating information and research • Advocating for user empowerment and human rights

27. 4) Advocating for user empowerment and human rights Indicators: • 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.

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

30. Key issues of Users • Acceptence/Empowerment • Inclusion/Involvement • Housing • Employment • Education • Policy • Human Rights • Stigma-Discrimination • Inequality • Treatment & Services

31. POWER • AUTHORITY

34. 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*

36. 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”

37. 20th Century Model Policlinics Primary Care Primary Care Policlinics Hospital Policlinics Primary Care

38. Service Model 21st Century Residential Care Secure places Acute Hospital Inclusion and rehabilitation CMHTs Primary Care

40. 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.

41. The Horizontal ideology

42. The concepts of a (N-G-R)PPCPN=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”

43. The creation of a horizontal Hybrid STATE Mental Health MARKET Civil Society

44. The creation of a horizontal Hybrid STATE MARKET Civil Society Mental Health

46. Ministry of Health, Social affairs & governm agencies MH Objectives, National Health strategy A Collaborative National Mental Health Project implementation Corporate resources Driving force and motivation Idea Civil Society (Mental Health ngo’s)

47. Inclusion of Civil Society (ICS)

48. The Horizontal ideologyInclusion of Civil Society (ICS) ALBANIAIdea  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.

49. Ministry of Health, Social affairs & governm agencies MH Objectives, National Health strategy National partner WHO A Collaborative National Mental Health Project implementation Driving force and motivation Civil Society (Mental Health Coalition of ngo’s) CS partners