The patient’s perspective

cult to be a psychiatric patient, a good doctor can make it less so. Confusion and fear can be overcome by knowledge and compassion, and resistance to treatment is often, although by no means always, amenable to change by intelligent persuasion. The devil, as the ﬁ ery melancholic Byron knew, is in the details. when ﬁ given psychiatric

It is diffi cult to be a psychiatric patient, but a good doctor can make it less so. Confusion and fear can be overcome by knowledge and compassion, and resistance to treatment is often, although by no means always, amenable to change by intelligent persuasion. The devil, as the fi ery melancholic Byron knew, is in the details.
Patients, when fi rst given a psychiatric diagnosis, are commonly both relieved and frightened-relieved because often they have been in pain and anxiety for a considerable period of time, and frightened because they do not know what the diagnosis means or what the treatment will entail. They do not know if they will return to the way they once were, whether the treatment they have been prescribed will or will not work, and, even if it does work, at what cost it will be to them in terms of their notions of themselves, potentially unpleasant side-effects, and the reactions of their family members, friends, colleagues, and employers. Perhaps most disturbing, they do not know if their depression, psychosis, anxieties, or compulsions will return to become a permanent part of their lives. Caught in a state often characterized by personal anguish, social isolation and confusion, newly diagnosed patients fi nd themselves on a quest to regain a sense of mastery of themselves and their surroundings. One of the main goals of therapies of all types is to empower the patient and give them some control back over their world.
The specifi cs of what the doctor says, and the manner in which he or she says it, are critically important. Most patients who complain about receiving poor psychiatric care do so on several grounds: their doctors, they feel, spend too little time explaining the nature of their illnesses and treatment; they are reluctant to consult with or actively involve family members; they are patronizing, and do not adequately listen to what the patient has to say; they do not encourage questions or suffi ciently address the concerns of the patient; they do not discuss alternative treatments, the risks of treatment, and the risks of no treatment; and they do not thoroughly forewarn about side-effects of medications.
Most of these complaints are avoidable. Time, although diffi cult to come by, is well spent early on in the course of treatment when confusion and hopelessness are greatest, non-adherence is highest, and the possibility of suicide substantially increased. Hope can be realistically extended to patients and family members, and its explicit extension is vital to those whose illnesses have robbed them not only of hope, but of belief in themselves and their futures. The hope provided needs to be tempered, however, by an explication of possible diffi culties yet to be encountered: unpleasant sideeffects from medications, a rocky time course to meaningful recovery which will often consist of many discouraging cycles of feeling well, only to become ill again, and the probable personal, professional, and fi nancial repercussions that come in the wake of having a psychiatric illness.
It is terrifying to lose one's sanity or to be seized by a paralysing depression. No medication alone can substitute for a good doctor's clinical expertise and the kindness of a doctor who understands both the medical and psychological sides of mental illness. Nor can any medication alone substitute for a good doctor's capacity to listen to the fears and despair of patients trying to come to terms with what has happened to them. A good doctor is a therapeutic optimist who is able to instill hope and confi dence to combat confusion and despair. Great doctors are able to provide the unwavering care to their patients that they would want a member of their own family to receive, blending empathy, and compassion with expertise.
Doctors need to be direct in answering questions, to acknowledge the limits of their understanding, and to encourage specialist consultations when the clinical situation warrants it. They also need to create a therapeutic climate in which patients and their families feel free, when necessary, to express their concerns about treatment or to request a second opinion. Treatment non-adherence, one of the major causes of unnecessary suffering, relapse, hospitalization, and suicide, must be addressed head-on. Young males, early in the course of their illness, are particularly likely to stop medication against medical advice, and the results can be lethal. (1,2) Unfortunately, doctors are notoriously variable in their ability to assess and predict adherence in their patients. (3) Asking directly and often about medication concerns and side-effects, scheduling frequent follow-up visits after the initial diagnostic evaluation and treatment recommendation, and encouraging adjunctive psychotherapy, or involvement in patient support groups, can make a crucial difference in whether or not a patient takes medication in a way that is most effective. Aggressive treatment of unpleasant or intolerable side-effects, minimizing the dosage and number of doses, and providing ongoing, frequently repetitive education about the illness and its treatment are likewise essential, if common-sense, ways to avert or minimize non-adherence.
Education is, of course, integral to the good treatment of any illness, but this is especially true when the illnesses are chronic. The term 'doctor' derives originally from the Latin word for teacher, and it is in their roles as teachers that doctors provide patients with the knowledge and understanding to combat the confusion and unpredictability that surrounds mental illness. Patients and their family members should be encouraged to write down any questions they may have, as many individuals are intimidated once they fi nd themselves in a doctor's offi ce. Any information that is given orally to patients should be repeated as often as necessary (due to the cognitive diffi culties experienced by many psychiatric patients, especially when acutely ill or recovering from an acute episode) and, whenever feasible, provided in written form as well. Additional information is available to patients and family members in books and pamphlets obtainable from libraries, bookstores, and patient support groups, as well as from audiotapes, videotapes, and the Internet. (2,4) Visual aids, such as charts portraying the natural course of the treated and untreated illness, or the causes and results of sleep deprivation and medication cessation, are also helpful to many. (5)(6)(7) Finally, providing the patients with self-report scales to monitor their daily progress, such as mood charts in affective disorder, not only provides invaluable clinical data, but also teaches patients to better understand their own illness and its response to therapeutic interventions as well as exacerbating stressors. Patients, when they are well, often benefi t from a meeting with their family members and their doctor, which focuses upon drawing up contingency plans in case their illness should recur. These meetings also provide an opportunity to shore up the support system the patient has by educating their caregivers about the nature, cause, manifestations, and treatment of their loved one's mental illness. Such meetings may also include what is to be done in the event that hospitalization is required and the patient refuses voluntary admission, a discussion of early warning signs of impending psychotic or depressive episodes, methods for regularizing sleep and activity patterns, techniques to protect patients fi nancially, and ways to manage suicidal behaviour should it occur. Suicide is the major cause of premature death in the severe psychiatric illnesses, (8,9) and its prevention is of fi rst concern. Those illnesses most likely to result in suicide (the mood disorders, comorbid alcohol and drug abuse, and schizophrenia) need to be treated early, aggressively, and often for an indefi nite period of time. (2,10) The increasing evidence that treatment early in psychiatric illness may improve the long-term course needs to be considered in light of the reluctance of many patients to stay in treatment. (10,11) No one who has treated or suffered from mental illness would minimize the diffi culties involved in successful treatment. Modern medicine gives options that did not exist even 10 years ago, and there is every reason to expect that improvements in psychopharmacology, psychotherapy, and diagnostic techniques will continue to develop at a galloping pace. Still, the relationship between the patient and doctor will remain central to the treatment, as Morag Coate wrote 35 years ago in Beyond All Reason: (12) Because the doctors cared, and because one of them still believed in me when I believed in nothing, I have survived to tell the tale. It is not only the doctors who perform hazardous operations or give lifesaving drugs in obvious emergencies who hold the scales at times between life and death. To sit quietly in a consulting room and talk to someone would not appear to the general public as a heroic or dramatic thing to do. In medicine there are many different ways of saving lives. This is one of them.

Introduction
The starting point for this discussion is the idea of stigma. This term (plural stigmata) was originally used to refer to an indelible dot left on the skin after stinging with a sharp instrument, sometimes used to identify vagabonds or slaves. (1)(2)(3)(4) In modern times stigma has come to mean 'any attribute, trait or disorder that marks an individual as being unacceptably different from the 'normal' people with whom he or she routinely interacts, and that elicits some form of community sanction.' (5)(6)(7)
ii) Stereotyping, which is the linkage of these differences to undesirable characteristics.
iii) Separating, the categorical distinction between the mainstream/normal group and the labelled group as in some respects fundamentally different. iv) Status loss and discrimination: devaluing, rejecting, and excluding the labelled group. Interestingly, more recently the authors of this model have added a revision to include the emotional reactions which may accompany each of these stages. (21,22)

Shortcomings of work on stigma
Five key features have limited the usefulness of stigma theories. First, while these processes are undoubtedly complex, academic writings on stigma (which in the fi eld of mental health have almost entirely focused upon schizophrenia) have made relatively few connections with legislation concerning disability rights policy (23) or clinical practice. Second, most work on mental illness and stigma has been descriptive, overwhelmingly describing attitude surveys or the portrayal of mental illness by the media. Very little is known about effective interventions to reduce stigma. Third, there have been notably few direct contributions to this literature by service users. (24) Fourth, there has been an underlying pessimism that stigma is deeply historically rooted and diffi cult to change. This has been one of the reasons for the reluctance to use the results of research in designing and implementing action plans. Fifth, stigma theories have de-emphasized cultural factors and paid little attention to the issues related to human rights and social structures.
Recently there have been early signs of a developing focus upon discrimination. This can be seen as the behavioural consequences of stigma, which act to the disadvantage of people who are stigmatized. (23,(25)(26)(27) The importance of discriminatory behaviour has been clear for many years in terms of the personal experiences of service users, in terms of devastating effects upon personal relationships, parenting and childcare, education, training, work, and housing. (28) Indeed, these voices have said that the rejecting behaviour of others may bring greater disadvantage than the primary condition itself.
Stigma can therefore be seen as an overarching term that contains three important elements: (29) ◆ problems of knowledge ignorance ◆ problems of attitudes prejudice ◆ problems of behaviour discrimination

Ignorance: the problem of knowledge
At a time when there is an unprecedented volume of information in the public domain, the level of accurate knowledge about mental illnesses (sometime called 'mental health literacy') is meagre. (30) In a population survey in England, for example, most people (55 per cent) believe that the statement 'someone who cannot be held responsible for his or her own actions' describes a person who is mentally ill. (31) Most (63 per cent) thought that fewer than 10 per cent of the population would experience a mental illness at some time in their lives. There is evidence that deliberate interventions to improve public knowledge about depression can be successful, and can reduce the effects of stigmatization. At the national level, social marketing campaigns have produced positive changes in public attitudes towards people with mental illness, as shown recently in New Zealand and Scotland. (32,33) In a campaign in Australia to increase knowledge about depression and its treatment, some states and territories received this intensive, co-ordinated programme, while others did not. In the former, people more often recognized the features of depression, were more likely to support help seeking for depression, or to accept treatment with counselling and medication. (34) Prejudice: the problem of negative attitudes Although the term prejudice is used to refer to many social groups, which experience disadvantage, for example minority ethnic groups, it is employed rarely in relation to people with mental illness. The reactions of a host majority to act with prejudice in rejecting a minority group usually involve not just negative thoughts but also emotion such as anxiety, anger, resentment, hostility, distaste, or disgust. In fact prejudice may more strongly predict discrimination than do stereotypes. Interestingly, there is almost nothing published about emotional reactions to people with mental illness apart from that which describes a fear of violence. (35) Discrimination: the problem of rejecting and avoidant behaviour Surveys of attitude and social distance (unwillingness to have social contact) usually ask either students or members of the general public what they would do in imaginary situations or what they think 'most people' who do, for example, when faced with a neighbour or work colleague with mental illness. Important lessons have fl owed from these fi ndings. This work has emphasized what 'normal' people say without exploring the actual experiences of people with mental illness themselves about the behaviour of normal people towards them. Further it has been assumed that such statements (usually on knowledge, attitudes, or behavioural intentions) are congruent with actual behaviour, without assessing such behaviour directly. Such research has usually focussed on hypothetical rather than real situations, neglecting emotions, and the social context, thus producing very little guidance about interventions that could reduce social rejection. In short, most work on stigma has been beside the point.

Global patterns
Do we know if discrimination varies between countries and cultures? The evidence here is stronger, but still frustratingly patchy. (36) Although studies on stigma and mental illness have been carried out in many countries, few have been comparison of two or more places, or have included non-Western nations. (37) In Africa one study described attitudes to mentally ill people in rural sites in Ethiopia. Among almost 200 relatives of people with diagnoses of schizophrenia or mood disorders, 75 per cent said that they had experienced stigma due to the presence of mental illness in the family, and a third (37 per cent) wanted to conceal the fact that a relative was ill. Most family members (65 per cent) said that praying was their preferred of treating the condition. (38) Among the general population in Ethiopia schizophrenia was judged to be the most severe problem, and talkativeness, aggression, and strange behaviour were rated as the most common symptoms of mental illness. (39) The authors concluded that it was important to work closely with traditional healers.
In South Africa, (40,41) a survey was conducted of over 600 members of the public on their knowledge and attitudes towards people with mental illness. (42) Different vignettes, portraying depression, schizophrenia, panic disorder, or substance misuse were presented to each person. Most thought that these conditions were either related to stress or to a lack of willpower, rather than seeing them as medical disorders. (43) Similar work in Turkey, (44) and in Siberia and Mongolia (45) suggests that people in such countries may be more ready to make the individual responsible for his or her mental illness and less willing to grant the benefi ts of the sick role.
Most of the published work on stigma is by authors in the USA and Canada, (11,27,46,47) but there are also a few reports from elsewhere in the Americas and in the Caribbean. (48) In a review of studies from Argentina, Brazil, Dominica, Mexico, and Nicaragua, mainly from urban sites, a number of common themes emerged. The conditions most often rated as 'mental illnesses' were the psychotic disorders, especially schizophrenia. People with higher levels of education tended to have more favourable attitudes to people with mental illness. Alcoholism was considered to be the most common type of mental disorder. Most people thought that a health professional needs to be consulted by people with mental illnesses. (49) A great deal of work has studied the question of stigma towards mentally ill people in Asian countries and cultures. (50-52) Within China, (53) a large scale survey was undertaken of over 600 people with a diagnosis of schizophrenia and over 900 family members. (54) Over half of the family members said that stigma had an important effect on them and their family, and levels of stigma were higher in urban areas and for people who were more highly educated.
In the fi eld of stigma research we fi nd that schizophrenia is the primary focus of interest. It is remarkable that there are almost no studies, for example, on bipolar disorder and stigma. A comparison of attitudes to schizophrenia was undertaken in England and Hong Kong. As predicted, the Chinese respondents expressed more negative attitudes and beliefs about schizophrenia, and preferred a more social model to explain its causation. In both countries most participants, whatever their educational level, showed great ignorance about this condition. (55) This may be why most of population in Hong Kong are very concerned about their mental health and hold rather negative views about mentally ill people. (56) Less favourable attitudes were common in those with less direct personal contact with people with mental illness (as in most Western studies), and by women (the opposite of what has been found in many Western reports). (57) Little research on stigma has been conducted in India. Among relatives of people with schizophrenia in Chennai (Madras) in Southern India, their main concerns were: effects on marital prospects, fear of rejection by neighbours, and the need to hide the condition from others. Higher levels of stigma were reported by women and by younger people with the condition. (58) Women who have mental illness appear to be at a particular disadvantage in India. If they are divorced, sometimes related to concerns about heredity, (59) then they often receive no fi nancial support from their former husbands, and they and their families experience intense distress from the additional stigma of being separated or divorced. (60) In Japan mental illnesses are seen to refl ect a loss of control, and so are not subject to the force of will power, both of which lead to a sense of shame. (61-63) Although, it is tempting to generalize about the degree of stigma in different countries, reality may not allow such simplifi cations. A comparison of attitudes to mentally ill people in Japan and Bali, for example showed that views towards people with schizophrenia were less favourable in Japan, but that people with depression and obsessive-compulsive disorder were seen to be less acceptable in Bali. (64) What different countries do often share is a high level of ignorance and misinformation about mental illnesses. A survey of teachers' opinions in Japan and Taiwan showed that relatively few could describe the main features of schizophrenia with any accuracy. The general profi le of knowledge, beliefs, and attitudes was similar to that found in most Western countries, although the degree of social rejection was somewhat greater in Japan. (65) In a unique move aimed to reduce social rejection, the name for schizophrenia has been changed in Japan. Following a decade of pressure from family member groups, including Zenkaren, the name for this condition was changed from seishi buntetsu byo (split-mind disorder) to togo shiccho sho (loss of co-ordination disorder). (66,67) The previous term went against the grain of traditional, culturally-valued concepts of personal autonomy, as a result of which only 20 per cent of people with this condition were told the diagnosis by their doctors. (68-70) There are indications from service users and family members that the new term is seen as less stigmatizing and is more often discussed openly.
Little is written in the English language literature on stigma in Islamic communities, but despite earlier indications that the intensity of stigma may be relatively low, (52) detailed studies indicate that on balance, it is no less than we have seen described elsewhere. (71-74) A study of family members in Morocco found that 76 per cent had no knowledge about the condition, and many considered it chronic (80 per cent), handicapping (48 per cent), incurable (39 per cent), or linked with sorcery (25 per cent). Most said that they had 'hard lives' because of the diagnosis. (75) Turning to religious authority fi gures is reported to be common in some Moslem countries. (76,77) Some studies have found that direct personal contact was not associated with more favourable attitudes to people with mental illness, (78,79) especially where behaviour is seen to threaten the social fabric of the community. (80,44) What sense can we make of all these fragments of information? Several points are clear. First there is no known country, society, or culture in which people with mental illness are considered to have the same value and to be as acceptable as people who do not have mental illness. Second, the quality of information that we have is relatively poor, with very few comparative studies between countries or over time. Third, there do seem to be clear links between popular understandings of mental illness, if people in mental distress want to seek help, and whether they feel able to disclose their problems. (81) The core experiences of shame (to oneself and for others) and blame (from others) are common everywhere stigma has been studied, but to differing extents. Where comparisons with other conditions have been made, then mental illnesses are more, or far more, stigmatized, (82,83) and have been referred to as the 'ultimate stigma' (9) . Finally, rejection and avoidance of people with mental illness appear to be universal phenomena.

Conclusions
If we deliberately shift focus from stigma to discrimination, there are a number of distinct advantages. First attention moves from attitudes to actual behaviour, not if an employer would hire a person with mental illness, but if he or she does. Second, interventions can be tried and tested to see if they change behaviour towards people with mental illness, without necessarily changing knowledge or feelings. The key candidates as active ingredients to reduce stigma are: (i) at the local level, direct social contact with people with mental illness; (84-86) and (ii) social marketing techniques at the national level. Third, people who have a diagnosis of mental illness can expect to benefi t from all the relevant anti-discrimination policies and laws in their country or jurisdiction, on a basis of parity with people with physical disabilities. Fourth, a discrimination perspective requires us to focus not upon the 'stigmatized' but upon the 'stigmatizer' . In sum, this means sharpening our sights upon human rights, upon injustice, and upon discrimination as actually experienced by people with mental illness. (7,24,87,88) Further information Thornicroft

Mental disorders as a worldwide public health issue
Benedetto Saraceno

Magnitude and burden of mental disorders
The twentieth century has witnessed signifi cant improvements in somatic health in most countries. A number of key public health threats have been eradicated or brought under control under the leadership of WHO. Priority was given to communicable diseases in view of their inherent potential to spreading. At the present time, a focus on non-communicable diseases and mental health would now appear as the next natural step in public health priorities. In the case of mental health, this is due to the capacity of mental disorders to proliferate not only as a result of complex and multiple biological, psychological but also social determinants. WHO estimates that at any given time 450 million people suffer from some form of mental or brain disorder, including alcohol and substance use disorders. In other words, one in four of the world's population suffer from different forms of mental, behavioural, and neurological disorders. (1) The World Development Report: investing in health (2) and the development of the disability-adjusted life-year for estimating the global burden of disease, including years lost because of disability (3,4) and the World Health Report 2001, have all raised the awareness of the global burden of mental disorders. Mental disorders already account for more than 13.46 per cent of the GBD. Furthermore, it is estimated that by the year 2015, the GBD from all neuropsychiatric illnesses will reach 14.14 per cent and by 2030, 14.42 per cent. According to WHO, mental disorders accounted for 6 of the 20 leading causes of disability worldwide for the 15-44 age group, the most productive section of the population. (1) While a greater proportion of the burden is found in high-income countries (21.4 per cent) including those with formerly socialist economies (16.4 per cent), low-and middle-income countries are greatly affected and are likely to see a disproportionately large increase in the burden attributable to mental disorders in the coming decades as infectious diseases are brought under better control and as the population ages. The growing burden of mental, neurological, and substance use disorders is exacerbated in low and middle-income countries due to a projected increase in the number of young people entering the age of risk for the onset of certain mental disorders. An estimated 849 000 people commit suicide every year. This fi gure represents 1.4 per cent of the global burden of disease as estimated using Disability Adjusted Life Years (DALY) methodology. The proportion of the global disease burden due to suicide varies from 0.2 per cent in Africa up to 2.5 per cent in the Western Pacifi c region. In the European, South East Asian, and Western Pacifi c regions, this proportion exceeds the world average. Suicide among young people is of signifi cant concern; in some regions, suicide is the third leading cause of death in the age group of 15-35 years. Suicide is the leading cause of death for this age group in China and the second in the European region. Alcohol consumption alone is responsible for 4 per cent of the global disease burden. (5) In 2000, the global use of alcohol was estimated to have caused 1.8 million deaths or 3.2 per cent of the total deaths from all causes that year. It is estimated that 2.2 million people died from alcohol-related causes in 2005 and increase of 22 per cent from 2000. The population of injecting drug users comprises approximately 10 million people worldwide. Globally, 4-12 per cent of all HIV cases are due to injection drug use, a driving force behind the HIV/AIDS epidemic in many parts of the world.

Economic and social costs of mental disorders
The economic and social costs of mental disorders fall on societies, governments, people with mental disorders, and their carers and families. Given the long-term nature of mental disorders, the most evident economic burden is that of direct treatment costs. For example, the most important contributor to direct costs of depression is hospitalization, accounting for around half of the total in the United Kingdom and three-quarters in the United States. (6) However a common fi nding from studies of the economic burden of mental disorders in high-income countries is that the 'indirect' costs of lost productivity and premature mortality outweigh the 'direct' costs of treatment and care. (7) Three recent mental health economic studies carried out in India have likewise shown that lost production and other time costs greatly exceed the costs of targeted clinical intervention. (8)(9)(10) In most countries, families bear a signifi cant proportion of these economic costs because of the absence of publicly funded comprehensive mental health service networks. However, ulti mately governments and societies pay a price in terms of reduced national income and increased expenditure on social welfare programmes. Thus, the economic logic for societies and countries is simple: treating mental disorders is expensive but leaving them untreated can be more expensive.
In addition to the obvious suffering caused by mental disorders there is a hidden burden of stigma and discrimination and human rights violations. Rejection, unfair denial of employment opportunities and discrimination in access to services, health insurance, and housing are common as are violations of basic human rights and freedoms, as well as denials of civil, political, economic, and social rights, in both institutions and communities. Much of this goes unreported and therefore the burden remains unquantifi ed. Families and primary care providers also incur social costs, such as the emotional burden of looking after disabled family members, diminished quality of life, social exclusion, stigmatization, and loss of future opportunities for self-improvement.

Global resources for mental health
The WHO survey of mental health resources (Project Atlas) highlighted the huge existent gap between the burden of mental disorders and available resources. (11,12)

Mental health policy and legislation
Mental health services and strategies must be well coordinated with other services, such as social security, education, and public interventions in employment and housing through an adequate mental health policy. In spite of this, only 62 per cent of countries have a policy in the mental health fi eld (see Table 1.3.1.1). Mental health legislation is essential to guarantee the dignity of patients and protect their fundamental human rights, though 22 per cent of countries do not have legislation in the fi eld of mental health.

Mental health budget
In spite of the importance of mental health burden in the world (representing more than 13.46 per cent of global burden of diseases), out of only 101 countries that reported having a specifi c budget, 25 per cent spend less than 1 per cent of the total health budget on mental health (Fig. 1.3.1.1).

Methods of fi nancing mental health care
The tax-based method is the preferred method for fi nancing mental health care present in 63 per cent of countries ( Fig. 1.3.1.2), while all the countries with out-of-pocket fi nancing as the primary method are low-or middle-income countries. However, families of people with severe chronic mental disorders are often among the poorer and, in addition to the family burden, can access to basic mental health care.

Community care for mental health
Community care has a better effect than institutional treatment on the outcome and quality of life of individuals with chronic mental disorders. Globally, 68 per cent of countries reported to have at least some community care facilities for mental health. Community care facilities in mental health are only present in 52 per cent of the low-income countries versus 97 per cent of high-income countries.
Though community-based services are recognized to be most effective, 65 per cent of all psychiatric beds are still in mental hospitals-eating away the already meagre budgets while providing largely custodial care in an environment that violates basic human rights of inmates. (10) Fig. 1.3.1.1 Percentage of total health budget spent on mental health-countries (%) (N = 101)

Psychiatric beds
The distribution of psychiatric beds by setting across different income countries also varies. In low-income countries 74 per cent of the psychiatric beds are located in mental hospitals, while in high-income countries only 55 per cent. Across different regions, south-east Asia has 83 per cent of its psychiatric beds in mental hospitals compared with 64 per cent in the European region (see Table 1. 3.1.2). The Western Pacifi c region has the highest proportion of psychiatric beds in general hospitals (35 per cent), followed by Europe with 22 per cent of their total psychiatric beds.
In approximately 41 per cent of countries there is less than one psychiatric bed per 10 000 of the population. The proportion of beds which are not located in mental hospitals or in general hospitals includes those in private and military hospitals, hospitals for special groups of population or long-term rehabilitation centres.

Professionals working in mental health
All the countries in the south-east Asia region and most of countries in the African region have less than one psychiatrist per 100 000 population compared to 10 psychiatrist per 100 000 populations in the European region (see Table 1.3.1.3). The median number of psychiatric nurses per 100 000 population varies from 0.10 in the south-east Asia region to 25 in the European region.
The median number of psychologists in mental health per 100 000 population varies from 0.03 in the south-east Asia and Western Pacifi c region to 3.10 in the European region and 2.80 in the American region.
In the world there is less than one psychologist per 100 000 population in 61.6 per cent of countries and in low-income countries almost all the population has access to less than one psychologist per 100 000.
The median number of social workers working in mental health per 100 000 population varies from 0.04 in the south-east Asian region to 1.50 in the European region. In about 64 per cent of countries there is less than one social worker per 100 000 population. In the African and Eastern Mediterranean regions more than 85 per cent of the population has access to less than one social worker per 100 000 population.

Treatment gap for mental disorders
A large proportion of the individuals who suffer from mental disorders do not receive any health care for their condition. The treatment gap for most mental disorders is high. According to a recent review done by WHO from published sources, originating from the United States, Europe, Brazil, Chile, China, India, Zimbabwe, and others, (13) the percentages of people in need for treatment not receiving it are as follows (see Table 1.3.1.4).

Improving mental health care
The mental health infrastructure and services in most countries is grossly insuffi cient for the large and growing needs. In order to deliver a high standard of mental health treatment and care, WHO emphasizes the adoption of an integrated system of service delivery which attempts to comprehensively address the full range of psychosocial needs of people with mental disorders. A number of policy recommendations for service organizations have been highlighted in the World Health Report 2001. (1) They include (i) shifting care away from large psychiatric hospitals, (ii) developing community mental health services, and (iii) integrating mental health care into general health services. Essentially, ethical and scientifi c considerations have given impetus to the movement to transfer mental health care from mental hospitals to primary health care, general hospitals, and a range of community services in the expectation of enhancing accessibility and acceptability of services, achieving better 'mental' and 'physical' health outcomes, and also a better rationalization of resources.
A large part of mental health care can be self-managed and/or managed by informal community mental health services and lowcost resources can be made available in the community to this effect. Where additional expertise and support is needed a more formalized network of services is required. In ascending order these include primary care services, followed by psychiatric services based in general hospitals and formal community mental health services and lastly by specialist and long stay mental health services.
The mental health fi eld is developing rapidly. There is an evolving information base to guide policy, legislation, service development, and clinical practice. However, there remains a gap between what we know in terms of what works and what is actually occurring in practice in countries around the world. This gap needs to be closed by continued advocacy efforts to raise mental health on the agenda of governments, by continued dissemination of information on effective policies, service development and clinical practice, and the dissemination of international human right standards.
With the mass movements of populations that have characterized the second half of the twentieth century, there can be few psychiatrists who do not encounter members of an ethnic minority group in their practice. The principles of transcultural psychiatry are obviously of relevance to this type of psychiatrist-patient interaction, but they are also of central importance even when the psychiatrist and patient share the same ethnic background. This is because within a particular ethnic group there are invariably many subcultures, for example based on religious affi liation, which encompass a diversity of beliefs. It is essential that the psychiatrist be aware of the common belief systems likely to be encountered, not simply to enhance rapport with patients and relatives, but in order to avoid serious mistakes in ascribing pathology to experiences that are accepted as normal by the subculture. For example, it is important to be aware that between 10 and 17.5 per cent of the general population report experiencing psychotic symptoms. (1,2) The political repercussions of ignorance of such subcultural phenomena are illustrated by the accusations of misdiagnosis of Black patients by White psychiatrists which have come from both outside and within the profession. It is somewhat reassuring that the only published scientifi c study of this contention fails to support it. (3) There are two main streams of thought and enquiry that have shaped the development of transcultural psychiatry: social anthropology and psychiatric epidemiology. In a number of ways these disciplines are opposed; the former is concerned with qualitative data and emphasizes cultural relativity (see Chapter 2.6.2.), while the latter relies on quantitative data and prioritizes a search for universal disease categories (see Chapter 2.7). The tools of the epidemiologist are standardized interview schedules which are linked with defi nitions of symptoms and signs, and rules for reaching a diagnosis. These have been introduced in an attempt to reduce the subjectivity of the psychiatrist's judgement to a minimum. By contrast, it is the person's subjective experience of illness that is the prime focus of the anthropologist. Consequently the use of standardized psychiatric interviews has been criticized by anthropologists as imposing a western biomedical model of disease on the rich variety of experience of illness and distress. The two approaches are not mutually exclusive and are best viewed as contributing complementary material to our understanding of psychiatric morbidity. (4) The contribution of psychiatric epidemiology

Cultural infl uences on the psychoses
Epidemiologists have been keen to discover whether psychiatric conditions are universal and appear with the same incidence across human populations. Universality would minimize the role of culture in shaping the form of a condition, while a uniform incidence would indicate that biological factors played a major role in aetiology. Schizophrenia has been the focus of many epidemiological surveys, especially the cross-national studies conducted by the World Health Organization (WHO). The International Pilot Study of Schizophrenia (5) showed that it was possible to conduct a psychiatric epidemiological study across a wide variety of cultures and languages. (6) The use of standardized assessment and diagnostic techniques revealed that the core symptoms of schizophrenia were subject to few cultural variations. The most striking difference in the form of the illness was that catatonic symptoms were relatively frequent in patients from developing countries, but rare in the other centres.
The success of this study led to an even more ambitious projectthe Determinants of the Outcome of Severe Mental Disorders. The main aim was to collect epidemiologically based samples of psychotic patients making a fi rst contact with health services in centres around the world. It was found that the incidence of narrowly defi ned schizophrenia was remarkably uniform across a diversity of countries. (7) However, when patients with a broad diagnosis of schizophrenia but lacking the core Schneiderian symptoms were considered, the incidence rates across centres showed a threefold difference which was highly signifi cant. This suggests that socio-cultural factors are likely to play a much greater role in the aetiology of non-Schneiderian schizophrenia than in the narrowly defi ned form, although the nature of these factors remains to be determined.
Dramatic differences in outcome at a 2-year follow-up were found, patients with schizophrenia in developing centres faring considerably better than those in developed centres despite a paucity of psychiatric personnel and facilities. This was not explained by a higher proportion of cases with an acute onset in the developing centres, raising intriguing questions about the benefi cial aspects of traditional cultures. Explanations that have been proposed include beliefs that the causes of illness are external to the patient, the low demands for productivity and punctuality in an agrarian economy enabling the employment of disabled patients, and the quality of traditional family life. Only the latter has been investigated and appears to make an important contribution, since family carers in India are far less critical and more tolerant of patients with schizophrenia than their counterparts in Britain. (8) The existence of relatively large populations of people of ethnic minority status in developed countries has facilitated the study of cultural infl uences on psychoses. Such research has revealed a remarkably elevated incidence of both schizophrenia and mania in some of these groups. (9,10) Of a number of possible explanations, the most likely lie in the social environment. (11) Mania has been the focus of much less transcultural research than schizophrenia, but what little there is suggests that psychotic experiences are more common in Nigerian and African-Caribbean patients than in patients from European countries. (12,13)

Cultural infl uences on the neuroses (a) Variations in frequency across cultures
Whereas neither the form nor the incidence of psychoses vary much across cultures, neuroses show dramatic variations in both respects. So-called culture-bound syndromes are an extreme example of variation in frequency since it is claimed that they are confi ned to specifi c cultural groups (see Chapter 4.16.). It is an error to think of these as exotic manifestations in traditional societies, since eating disorders, while increasingly common in developed countries are infrequent elsewhere. (14) Even with common conditions such as depression, the range of prevalence rates from studies across cultures is extremely wide. (15) This is partly attributable to a greater focus on bodily symptoms in patients in developing countries. The signifi cance of somatic symptoms may well be missed by standardized interviews designed to detect the cognitive experiences of depression.
The emphasis on the measurement of prevalence of neuroses as opposed to incidence is due to the small proportion of new cases of neurosis that present to psychiatric services. In order to detect the majority of new cases of neuroses it is necessary to conduct population surveys, which are costly in terms of time and trained personnel. The few population surveys that have been conducted in both developed and developing countries using the same methods of interviewing and case ascertainment have shown either no difference in the prevalence of neuroses (16,17) or a higher rate in the developing country. (18,19)

(b) Variations in form across cultures
One of the most striking transcultural aspects of the neuroses is the great variation in the frequency of classical conversion hysteria. Whereas this condition is rarely seen in psychiatric and neurological services in developed countries today, it is still a common form of presentation in developing countries. (20) This is another manifestation of the tendency to present emotional distress in bodily terms that prevails in those cultures. Somatization is by no means uncommon in patients in developed countries, particularly in individuals of lower socio-economic status, but somatic symptoms are more likely to dominate the picture in patients in a developing country. This is determined partly by beliefs about illness (see Chapter 2.6.2.) and partly by mutual expectations of patients and doctors and of traditional healers, who treat the majority of people with neuroses in developing countries.

Help-seeking behaviour
In general people seek help from healers who hold the same beliefs as they do (see Chapter 7.3). Traditional healers in developing countries have the advantage of sharing the same belief system about illness with their clients, so that they can take for granted a great deal of common ground and do not need to embark on long explanations. Clients of traditional healers often present their distress in terms of somatic symptoms. Skilled healers are adept at understanding the relationship problems that underlie the client's bodily complaints, and their prescription of rituals is aimed at involving the client's social network and regularizing relationships. (21) Problems in communication arise when the patient brings somatic symptoms to the western trained doctor, who may fail to detect the emotional distress generating the symptoms (22) and is unable to recognize the relationship diffi culties that have prompted the comlaints.
Traditional healers are by no means confi ned to developing countries or to ethnic minority groups in developed countries. Alternative medicine fl ourishes where western biomedicine is perceived by the public to be ineffective, and psychiatry is one of those areas. Patients with psychiatric conditions are very likely to seek help from acupuncture, spiritual healing, homeopathy, or herbal remedies, in addition to consulting the general practitioner or psychiatrist. Sympathetic questioning of psychiatric patients will elicit their use of a number of sources of alternative medicine in their neighbourhood.

The concept of depression
At the same time as the evidence for a biological basis for depression appears to be strengthening, the western concept of depression has been criticized by transcultural researchers. Obeyesekere (23) considers that each culture has developed its own methods for dealing with painful emotions, for example, the Buddhists of Sri Lanka cope with the loss of a loved person by meditating on the illusory nature of the world of sense, pleasure, and domesticity. Obeyesekere (23) refers to these coping measures as 'the work of culture' and views the construction of a disease known as depression as a western cultural resource. Its incorporation into international classifi cations of diseases could be viewed as 'the imposition of western cultural standards that are presented as universal and inseparable parts of an emerging new world order'. (24) If a biological basis for the neuroses was fi rmly established such a formulation could be readily dismissed, but the effi cacy of non-biological treatments for depression and anxiety, such as cognitive therapy, couple therapy, and behaviour therapy, indicates that Obeyesekere's view deserves serious consideration. It represents a specifi c example of the general premise that western biomedicine is itself a cultural construction and needs to be seen as one of many different ways of dealing with the experience of illness and distress. (24) The achievement of biomedicine in ridding the world of smallpox and other fatal diseases is undeniable, but in the fi eld of psychiatry in particular we need to remain open to the ways other cultures have developed for helping people with what we would term psychiatric illness.