Psychiatry in Society Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) Psychiatry in Society Edited by Norman Sartorius University of Geneva, Switzerland Wolfgang Gaebel University of Du È sseldorf, Germany Juan Jose  Lo  pez-Ibor Complutense University of Madrid, Spain Mario Maj University of Naples, Italy Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) Copyright # 2002 by John Wiley & Sons, Ltd., Baffins Lane, Chichester, West Sussex PO19 1UD, UK National 01243 779777 International (+44) 1243 779777 e-mail (for orders and customer service enquiries): cs-books@wiley.co.uk Visit our Home Page on: http://www.wiley.co.uk or http://www.wiley.com Chapter 8, Saraceno et al., Copyright # 2002 World Health Organization. The WHO has granted John Wiley & Sons, Ltd, permission for the reproduction of this chapter. All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1P 0LP, UK, without the permission in writing of the publisher. 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World Congress of Psychiatry (11th: 1999: Hamburg, Germany) RC454.4.P7915 2002 362.2 0 042Ðdc21 2001057386 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-471-49682-0 Typeset in 10/12pt Palatino by Kolam Information Services Private Ltd, Pondicherry Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall This book is printed on acid-free paper responsibly manufactured from sustainable forestry, in which at least two trees are planted for each one used for paper production. Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) Contents List of Contributors vii Preface ix 1. The Impact of Sociocultural and Economic Changes on Psychiatry Leon Eisenberg 1 2. Changes in Health Care Systems and Their Impact on Mental Health Care Heinz Ha È fner 15 3. Globalization and Mental Health Glyn Lewis and Ricardo Araya 57 4. The Impact of Legislation on Mental Health Policy Jose  M. Bertolote, Jose  G. Taborda, Julio Arboleda-Flo  rez and Francisco Torres 79 5. The New Ethical Context of Psychiatry Ahmed Okasha 101 6. Community Mental Health Care: Promises and Pitfalls Paul Bebbington, Sonia Johnson and Graham Thornicroft 131 7. Quality of Life: A New Dimension in Mental Health Care Heinz Katschnig and Monika Krautgartner 171 8. Mental Health Problems in Refugees Benedetto Saraceno, Shekhar Saxena and Pallab K. Maulik 193 9. The Homeless Mentally Ill Viviane Kovess 221 10. Mental Health Consequences of Disasters Evelyn J. Bromet and Johan M. Havenaar 241 11. Mass Media and Psychiatry Olga Cuenca 263 Index 281 Acknowledgements 293 Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) Contributors Ricardo Araya Division of Psychological Medicine, Monmouth House, University of Wales College of Medicine, Heath Park, Cardiff, CF14 4XN, UK Julio Arboleda-Flo  rez Department of Psychiatry, Queen's University, Hotel Dieu Hospital, 166 Brock Street, Kingston, Ontario K7L 5G2, Canada Paul Bebbington Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, UCL (University College London), London, UK Jose  M. Bertolote Department of Mental Health and Substance Depend- ence, World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland Evelyn J. Bromet Department of Psychiatry, State University of New York at Stony Brook, Putnam Hall, South Campus, Stony Brook, NY 11793± 8790, USA Olga Cuenca J.A. Llorente & O. Cuenca, Communications Consultancy, Hermanos Becquer 4, Madrid, Spain Leon Eisenberg Department of Social Medicine, Harvard Medical School, 641 Huntington Avenue, 2nd Floor, Boston, MA 02115±6019, USA Heinz Ha È fner Schizophrenia Research Unit, Central Institute of Mental Health, J 5, D-68159 Mannheim, Germany Johan M. Havenaar Altrecht Institute for Mental Health Care, Vrouwjut- tenhof 18, 3512 PZ Utrecht, The Netherlands Sonia Johnson Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, UCL (University College London), London, UK Heinz Katschnig Department of Psychiatry, University of Vienna, Waeh- ringerguertel 18±20, A-1090 Vienna, Austria Viviane Kovess Public Health Research Department, MGEN, Paris V University, France Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) Monika Krautgartner Department of Psychiatry, University of Vienna, Waehringerguertel 18±20, A-1090 Vienna, Austria Glyn Lewis Division of Psychological Medicine, Monmouth House, Uni- versity of Wales College of Medicine, Heath Park, Cardiff, CF14 4XN, UK Pallab K. Maulik Department of Mental Health and Substance Depen- dence, World Health Organization, CH-1211 Geneva 27, Switzerland Ahmed Okasha WHO Collaborating Center for Research and Training in Mental Health, Institute of Psychiatry, Ain Shams University, 3, Sha- warby Street, Kasr El Nil, Cairo, Egypt Benedetto Saraceno Department of Mental Health and Substance De- pendence, World Health Organization, CH-1211 Geneva 27, Switzerland Shekhar Saxena Department of Mental Health and Substance Depen- dence, World Health Organization, CH-1211 Geneva 27, Switzerland Jose  G. Taborda Faculty of Medicine, Universidade Luterana do Brazil, Rua Bororo  55, 91900±540 Porto Alegre, RS, Brazil Graham Thornicroft Health Services Research, The David Goldberg Cen- tre Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK Francisco Torres Universidad de Granada, Departamento de Psiquiatrõ  a, Facultad de Medicina, Avenida de Madrid 11, 18071 Granada, Spain viii CONTRIBUTORS Preface Some time ago one of us wrote that social psychiatry will disappear and that it is likely that ``the world will be a slightly better place without it'' [1]. The reason for this statement was that it is unimaginable that psychiatry could be practised or that psychiatric research could be conducted without con- stant reference to social factors and to the social environment. It was agreed that it is therefore unnecessary to have social psychiatry as a special discip- lineÐall psychiatry being also socialÐbut it is also harmful to use this term because the existence of social psychiatry could be taken as a proof that good psychiatry can exist without its social component. The changes of the social context affect the incidence and prevalence of mental disorders, their course and outcome, and their reaction to treatment. Social changes are also of determinant importance for the rehabilitation of people who had mental illness. They affect, furthermore, the organization of health care, the training of health care staff, and the willingness and capacity of families to look after their sick members. This volume brings together 11 contributions, each of which deals with the interaction between psychiatry and a particular set of social factors. Thus, Eisenberg explores the impact of medical ideology on psychiatric care; Ha È fner's chapter examines the influence of changes in health care systems on mental health care; Bertolote et al., Okasha, and Lewis and Araya, respectively, examine the legal, ethical and economic contexts of care and their influence on psychiatry. Mass media and psychiatry are examined in Cuenca's chapter; the impact of disasters in Bromet and Have- naar's text; Saraceno et al., Kovess, and Bebbington et al. deal with the special social circumstances under which care is or should be provided. There are numerous indicators of the manner in which social environments and psychiatry interact; of those, quality of life has been selected for detailed examination because it is the most relevant outcome of the interaction between social contexts and care for people with mental illness, and Katsch- nig and Krautgartner's chapter addresses that issue. There are many other areas on the interface between social development and psychiatry which will not be covered by this volume; this is the un- avoidable consequence of limitation of space and time allotted for the production of the volume. Two among those omissions, however, deserve special mention. The first of themÐstigma and discrimination because of mental illnessÐis at present the most important obstacle to the provision of Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) care for people with mental illness. Several national programmes to combat stigma have been started recently (e.g., in Australia, Sweden, and the UK) and the World Psychiatric Association (WPA) has launched a major multi- site programme to deal with stigma because of schizophrenia. The results from these programmes have begun to emerge and their presentation will be given a special place in the scientific programme of the next World Congress of Psychiatry in Yokohama, Japan, in 2002. Similarly, the practice of psychiatry under conditions of extreme financial scarcity has been selected as an institutional programme of the WPA and will be a focal point for presentation during the Yokohama Congress. Chapters addressing those two areas of interest will thus be among those that will follow the Yokohama meeting. We hope that the materials assembled in this volume will stimulate and facilitate discussion about social factors and psychiatry. The World Bank has recently begun publishing materials and reports about the economic and social importance of mental illness; it would be deplorable to see psy- chiatrists absent from this type of debate and from the social arena within which psychiatry is firmly rooted and on which it depends in so many of its aspects. Norman Sartorius Wolfgang Gaebel Juan Jose  Lo  pez-Ibor Mario Maj REFERENCE 1. Sartorius N. (1988) Future directions: a global view. In Handbook of Social Psy- chiatry (Eds A.S. Henderson, G.D. Burrows), pp. 341±346, Elsevier, Amsterdam. This volume is based in part on presentations delivered at the 11th World Congress of Psychiatry (Hamburg, Germany, 6±11 August 1999) x PREFACE Acknowledgements The Editors would like to thank Drs Paola Bucci, Umberto Volpe and Andrea Dell'Acqua, of the Department of Psychiatry of the University of Naples, for their help in the processing of manuscripts. The publication has been supported by an unrestricted educational grant from Janssen-Cilag, which is hereby gratefully acknowledged. Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) CHAPTER 1 The Impact of Sociocultural and Economic Changes on Psychiatry Leon Eisenberg Department of Social Medicine, Harvard Medical School, Boston, MA, USA INTRODUCTION The distribution of health and disease in human populations reflects where people live, how they live, what they eat, the work they do, the air they breathe and the water they drink, their interconnectedness with others, the beliefs they hold about health and disease, and the organization and quality of health care available to them. The status they occupy in the social order determines their risk for disease, on the one hand, and their access to care, on the other. What they believe guides what they choose from among the options available to them. Because all human disease is social, changed social conditions alter the epidemiology and course of disease. Among the cultural factors influencing health care is the culture of medi- cine: the conventional wisdom taught to physicians that guides the actions they carry out. Part of the mystique of medical culture is the convenient fiction that the practice of medicine is simply the application of science to the treatment of disease. That may be what medicine aims to achieve, but much of daily practice is based on tradition, opinion, anecdote and folklore (for example, what grandmothers ``know'': that bed rest is good for the sick person). BELIEF AS A DETERMINANT OF CARE Paul Beeson [1] compared the treatments recommended in the first (1927) edition of Cecil's [2] Textbook of Medicine with those recommended in its fourteenth (1977) edition [3]. Enormous gains in medical knowledge had occurred during that half-century. The new knowledge enabled Beeson to Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj. # 2002 John Wiley & Sons, Ltd. Psychiatry in Society. Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Mario Maj Copyright # 2002 John Wiley & Sons Ltd. ISBNs: 0±471±49682±0 (Hardback); 0±470±84648±8 (Electronic) [...]... living conditions from day to day Thanks to this radical liberalism the riches and power of the British Empire grew, and the old, paternalistic ideal of solidarity and welfare fell into oblivion Originating in the belief in the blessings of relentless pursuit of selfinterest, the extreme forms of liberalism and capitalism practised in Great 22 PSYCHIATRY IN SOCIETY Britain were increasingly suffering... spans because of diabetes and its complications [50] The Nauru epidemic has ominous implications for Southeast Asia Rates of diabetes among Chinese and Indian expatriates living in the West (in contrast to low rates in China and India) make it virtually certain that the improved living standards anticipated for India and China in the next century will lead to epidemics of NIDDM [51] Social Class and Mental... 000 in 1908 to 30 000 in 1915, and from 80 000 in 1931 to 100 000 by mid-century The first randomized trial in clinical medicine [6] demonstrated the effectiveness of streptomycin in the treatment of tuberculosis Soon thereafter, p-amino-salicylic acid and isoniazid joined a growing list of effective chemotherapeutic agents Yet, lung specialists continued to insist upon bed rest as the essential ingredient... competing, though increasingly reciprocally influenced, value orientations in the existing health care systems The one holds that the government alone is responsible for providing health and social care, according to the principle of fairness, as well as protection against the financial risk of ill health for the entire population The other is the liberal tradition according to which state involvement in. .. certain section of society through prepaid contributions The distribution of the burden of health financing between the government, the working population and individual citizens is a key policy choice in any society The share in health financing paid by the government and the citizens is conversely related to the utilization of health services The objective of any health care system, providing financial... employers and employees pay their share In these systems, usually also family members are insured and the financial costs of ill health and disability are covered Their innate weakness is that only the working population makes a financial CHANGES IN HEALTH CARE SYSTEMS AND THEIR IMPACT 27 contribution In countries with declining working populations and increasing numbers of the elderly and the unemployed... epidemics from being brought in by ships' crews, rats and passengers The reduction of food-related risks, as by meat inspection and garbage removal, has long, but very different traditions in the leading cultures around the world Decisive improvement in the health of most nations, reflected in continued reductions in infant mortality and increases in life expectancy, began to occur in the second half of the... smallpox, unleashed in many countries enormous investments in the protection of drinking water, sanitation, garbage removal and nutritional hygiene The pace was almost breathtaking at which somatic medicine acquired numerous highly potent means of immunizing against and treating diseases Well into the 20th century remarkable improvement in public health occurred in those countries that could afford protective... after the evidence was in, that the Trudeau Society [7] finally abandoned bed rest as the bedrock of therapy Although many of the leading figures in the American Tuberculosis Society owned or operated sanatoria (and thus might have caused a conflict of interest), leading specialists with no financial stake were equally convinced that bed rest was essential The long lag in abandoning a useless (and costly)... subsuming under the criterion of fairness also the quality of the management of a health care system, which the WHO includes in the notion of stewardship: ``Fairness is a many-sided concept, broader than the concept of equity Fairness includes equity in health outcomes, in access to all forms of care and in financing Fairness also includes efficiency in management and allocation '' [4] They continue: . has ominous implications for Southeast Asia. Rates of diabetes among Chinese and Indian expatriates living in the West (in contrast to low rates in China and India) make it virtually certain that. expec- tation that months of inpatient care would follow. 4 PSYCHIATRY IN SOCIETY Just as I joined the Johns Hopkins staff, Blue Cross, the principal private insurer in Maryland, agreed for the. programs (including isolating infectious patients in sanatoria) and less crowded housing had reduced transmission. Doctors credited their treatments for the health tran- sition accompanying industrialization