FROM THE THIRD GENEVA CONFERENCE ON PERSON-CENTERED MEDICINE: SPECIAL INITIATIVES FOR PERSON-CENTERED CARE
The World Federation for Mental Health (WFMH) – International Network for Person-Centered Medicine (INPCM) Project:
Mental Health as a Priority: Adopting a Holistic Approach to Patient Care
Helen L Millar MBChB MRCPsycha and Mohammed T Abou-Saleh MPhil PhD FRCPsychb
a Consultant Psychiatrist, The Carseview Centre, Dundee, Scotland, UK
b Professor of Psychiatry & Consultant in Addiction Psychiatry, St George's, University of London, UK
The World Federation for Mental Health (WFMH) has a longstanding mission to promote the advancement of mental health awareness, of prevention of mental illness and of evidence-based interventions aimed at recovery of mental and physical wellbeing worldwide. The WFMH has advocated for international developments working to establish mental health policy and improve human rights. The WFMH has focused on promoting a holistic approach to patient care through key international programmes advancing the concept of treating the whole person. Among these programmes we highlight the ground breaking Body and Mind campaign, Keeping Care Complete survey and the Diabetes and Depression Dialogue. The World Federation for Mental Health’s Africa Initiative on the Mental Health Consequences of HIV/AIDS is a Call for Action for governments throughout Africa to give increased priority to the pressing need to improve the quality of mental health and psychosocial support services for people living with HIV/AIDS. The recent World Mental Health Day 2010 demonstrated a clear focus on the need to address mental health issues to achieve better compliance with treatment, health and social outcomes and improved quality of life for those living with chronic physical conditions. The WFMH’s most recent global effort - The Great Push - focuses on 4 main principles of Unity, Visibility, Rights and Recovery to emphasise the contribution of mental health to the overall disease burden worldwide. The WFMH has now joined with the INPCM in this international network to promote a person centered approach to care as a key area in international healthcare.
Dr. Helen L Millar, Consultant Psychiatrist, The Carseview Centre, 4 Tom McDonald Avenue, Dundee, Scotland, UK. E-mail: email@example.com
Accepted for publication: 26 January 2011
The World Federation for Mental Health (WFMH; www.wfmh.org) was founded in 1948 - the same time as the United Nations and the World Health Organization (WHO). It is an international non-governmental organization (NGO) with a mission to promote mental health awareness; prevention of mental disorders; advocacy and best practice including recovery focused evidenced-based interventions. Its members consist of organizations and individual members including users/carers representing over 5000 bodies from over 150 countries with members across all mental health disciplines. It has official NGO consultative status with the United Nations, WHO, UNESCO, International Labour Office and the World Bank .
Its major areas of strategic effort form the five pillars for the WFMH’s mission :
· Promotion and prevention of mental health
· Mental health information, education and awareness
· Promotion of recovery-focused interventions and services
· International development and advocacy constituency building
· Mental health policy and human rights
Table 1: WFMH Core Programs
The WFMH runs key core programmes along with major educational projects as shown in Table 1 and 2.
In 1992, the WFMH founded the World Mental Health Day (WMHD) Project which is a Global Mental Health Education Campaign to address the need to ‘make mental health a global prioirty’. The WMHD is the only annual global awareness campaign to focus attention on specific aspects of mental health and is commemorated in over 100 countries on October 2010 through local, regional and national WMHD commemorative events and programmes
The most recent campaigns have focused on the concept originally defined by the WHO back in 1948 of health as ‘A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ and updated recently in a further statement as ‘no health without mental health’ [3, 4] which has highlighted the contribution of mental health to the global burden of disease. Such a concept has led to a shift in emphasis on the need for health care systems to adopt a more integrative approach to health care to treat both mental and physical health in order to improve overall outcomes and quality of life.
The 2008 WFMH Day focused on ‘Making Mental Health a Global Priority’ for all people in all countries. In 2007 the release of The Lancet Series on Global Mental Health again brought global attention to the mental health movement around the world.  The series focused on the need for increased resources for mental disorders, treating and preventing mental disorders in low and middle income countries, reviewing and possibly changing the mental health systems in various countries and overcoming barriers to improve mental health services in low and middle income countries.
A striking gap was identified in terms of which services were available and which were needed to reduce the burden of mental disorders worldwide. The WFMH embraced the philosophy that community wellbeing flows from individual wellbeing. The task was outlined as changing the way mental illness was viewed, emphasizing its importance within the health care system in order to ensure illnesses are treated and individuals are properly served.
The 2009 WFMH Day theme “Mental Health in Primary Care: Enhancing Treatment and Promoting Mental Health” drew attention to the body of evidence which highlighted the benefits of enhancing overall health and promoting mental health by integrating healthcare services to allow equal access to care. The World Mental Health Day in 2009 aimed to provide consumers, carers and advocacy organizations with accessible information on this topic. The WFMH aimed to ensure that people with mental illnesses receive the same priority within the general and primary health care systems. This campaign followed on from WHO and the World Organization of Family Doctors (WONCA) release in 2008 of ‘Integrating Mental Health into Primary Care: A Global Perspective. WMHD 2009 highlighted the opportunities and challenges in integrating mental health care services into primary health care systems on a global level not only for patients and their carers, but also for health care professionals and
Table 2: WFMH Major Projects 2008-2010
providers. The barriers to these reforms have been reiterated endlessly. This campaign emphasised the need for governments and policy makers to address this issue as a priority outlining the reasons for the integration not only to improve health outcomes for the individual, but also for cost-effectiveness as primary care is less expensive. The WFMH emphasised the critical role of the mental health advocate and patient/service user in shaping this major health reform.
In 2010, the World Mental Health Day’s theme was entitled:”Mental Health and Long term Physical Illnesses”. This extended the concept of the ‘integration of care’ by focusing on the co – occurrence of physical and mental health disorders. The WHO has focused on 4 main chronic illnesses: cardiovascular disease, diabetes, cancer and respiratory illnesses which are responsible for 60% of the world’s deaths . Over the last two decades, evidence has demonstrated that people with chronic illnesses are more likely to suffer from depression and anxiety compared to the general population. Major depression with chronic physical health problems in turn increases the burden of the chronic illness, causes an increase in functional impairment and increases medical costs due to an increase in complications. The presence of a mental health problem with chronic physical illness also impairs self care and long term adherence with medication and treatment regimes.
The cost of co-morbidity is great in terms of social, personal and functional impairment. Mental illness contributes to worse outcomes in cardiovascular disease, diabetes, stroke, HIV and many other chronic physical illnesses. Many indicators suggest that people with mental illness and chronic physical illness struggle to obtain access to appropriate mental health care. There are a number of factors including lack of education and training in health care professionals, leading to non-identification of symptoms at an early stage and hence a lack of appropriate and timely intervention. If systems of care are integrated, there is an increased likelihood that mental health problems would be identified at an early stage and treated effectively. This would reduce the personal burden as well as minimize the social burden of illness and its long term medical costs.
In 2004 the WFMH highlighted the need for meaningful collaboration between health care professionals and people with mental health problems and their care givers/families in a call to action campaign toolkit for Metabolic Syndrome and Mental Health. It was based on emerging evidence and recommendations published in the Journal of Clinical Psychiatry (2005) highlighting the need for guidelines on monitoring and management of metabolic syndrome in diverse geographical and cultural settings.
At the time it had already been identified that the connection between severe mental illness and metabolic syndrome was emerging as an important public health concern and physical health problems such as obesity, hypertension and type 2 diabetes were increasingly recognized as occurring alongside mental illness. People with mental illness were recognized as having a reduced life expectancy compared to the general population and metabolic syndrome was a significant factor which needed to be addressed by health care professionals.
The WFMH considered that it was important to inform and educate all relevant stakeholders about metabolic disorders and promote best practice in managing metabolic syndrome. The materials provided in the tool kit were provided to promote optimal physical health monitoring for people with mental illnesses, raise awareness of the need to balance physical risks/benefits of antipsychotic medication and encourage people with mental illness to take responsibility for their physical health.
This was a unique global survey conducted by the WFMH in 8 countries gathering information from carers /relatives/families of those with severe mental illnesses (n=982) to assess their perspectives on health care provision, relapse prevention, recovery, stigma and what constitutes effective treatment.
The Keeping Care Complete Survey was targeted at helping to capture this unmet need for information in this important area. The survey aimed at improving the understanding of the daily challenges faced by carers /families of those with mental illnesses which at times is unrecognized by health care systems and the public. The results of the survey were revealing regarding the true concerns of carers and what they considered as complete care. The following summarise the conclusions to the survey questions:
· Medication cannot succeed in a vacuum – a holistic approach is required
· Family support and individual psychological support is crucial
· Exercise, a healthy diet and a stable lifestyle are key factors to overall wellbeing – not just control of symptoms
· Mental Health teams need to offer advice on diet, exercise and a healthy lifestyle options as well as input on alcohol/drugs and ensure regular physical health checks
· It is essential for caregivers to work along side mental health care professionals to ensure optimum outcomes
The Dialogue on Diabetes and Depression (DDD) is an international collaborative effort to examine the co-morbidity of diabetes and depression (www.diabetesand-depression.org). It was set up with the aim of reviewing the evidence to date in the field, defining gaps in knowledge and formulating strategies for prioritizing research and action in this important area. The grouping consists of global experts in the fields of mental and physical health from different health care systems. The WFMH was invited to join this initiative in order to provide the perspective from users/carers and provide valuable insights to strategies for the future delivery of services for these co-morbid conditions.
The Group’s international membership ensures that culture and country are considered along with the various factors affecting the development of these comorbid conditions. Individual working groups have already produced publications to inform the field in terms of epidemiology, effective interventions and addressed gaps in the knowledge on service provision at improving health care delivery in these co-morbid conditions. The overall outcome is aimed at improving the person’s experience of the treatment they receive and therefore the overall outcomes in terms of depression and diabetes.
As part of the WFMH’S contribution, an international awareness pack has been produced and is available on the WFMH website (www.wfmh.org). This pack provides solid evidence based information that can be used by organisations around the world to inform the general public on this important public health issue. The pack contains fact sheets which can be detached and reproduced separately. These include the following:
· Diabetes and Depression: an overview of International Efforts
· The Epidemiology of Diabetes and Depression
· The Diagnosis and Treatment of Depression and Diabetes
· The Role of Self Care in managing Depression and Diabetes
· The Role of Family Members in Helping to manage Diabetes and Depression
· Summary: What we know about Diabetes and Depression
The pack emphasizes the importance of self care in managing diabetes and depression. A critical component of the treatment which is often overlooked is self-empowerment and education, which improves the ability to care for oneself in the journey to recovery.
The WFMH is committed to working with international partners to disseminate this important information about diabetes and depression. From a public perspective, it is important to distribute this growing evidence base on the adverse consequences of these co-morbid conditions and available effective treatments. With appropriate awareness, information and resources, depression and diabetes can be more frequently recognized and effectively treated.
In 2008 the Lancet called on government and donors for ‘Action on Mental Health’ drawing attention to the impact of mental illness on the economies of countries and the wellbeing of the millions who go untreated [6,7]. As a majority of governments had been unresponsive, the WFMH formed a world campaign in strategic alliance with the Movement for Global Mental Health in 2010 in order to promote mental health on the international agenda with the following aims:
· To increase visibility of mental health problems to the general public and governments
· To address the stigma and the abuse of human rights associated with mental illness
· To improve the opportunities for treatment and recovery
· To pressurize governments to take appropriate action
The campaign is now encapsulated in the theme for 2011: “The Great Push: Investing in Mental Health.” The essential elements of the campaign are focussed on: (i) Unity; (ii) Visibility; (iii) Rights and (iv) Recovery.
Perceptions of disunity in the mental health world need to be dispelled. In the initial WFMH Great Global Consensus, there appeared to be substantial agreement on fundamental issues. Mental Health visibility remains poor and stigma high. WFMH support for mental health issues must be made more public – hence the theme for the next World Mental Health Day will be to highlight the importance of good mental health and the need for more investment in this area by governments. Appalling conditions exist in many mental health hospitals including abuse of human rights and lack of mental health legislation to safeguard them. Governments must not be allowed to remain silent on these matters. The WFMH has proposed the setting up of a Centre for Mental Health and Human Rights to tackle such issues with governments.
Thousands of individuals receive no mental health care because of the absence of mental health care professionals to assess and diagnose their illnesses. This is the first rate limiting step to recovery. Recently, methods for mental health screening and diagnosis have been developed using computer technology to empower nurses and health assistants, aimed at improving the detection, diagnosis and treatment of mental illness. Pilot studies are ongoing in India, Europe and Australia which are proving to be promising with a view to bringing treatment and relief to those who would otherwise go undiagnosed.
The WFMH has shown a clear commitment to the Person-centered Medicine Movement since its launch . At the recent Third Geneva Conference on Person-centered Medicine, the WFMH, joined in the clear united collaborative effort across disciplines and specialties. There was a strong commitment to the promotion of health as a state of physical, mental social and spiritual wellbeing as well as the relief of suffering related to physical and mental ill health. Support was shown for the universal adoption of the slogan ‘ No Health without Mental Health’.
The WFMH has demonstrated its ongoing dedication to this endeavour by a formal agreement to commit to the development of a task force composed of affiliated associations and organizations. The WFMH believes that it is well positioned to inform the INPCM movement of users/families perspectives in collaboration with the European Federation of Associations of Families with Mental Illness (EUFAMI). The WFMH has also shown its commitment to the movement by forming an alliance with INPCM to promote a person-centered approach to care founded on evidence and humanism to improve understanding of illness and positive health on an individual basis as well as on a community and also global level. The WFMH is committed to further efforts to this perspective on health in order to promote the benefits of adopting a more holistic approach to care to improve health and social outcomes and quality of life for people with mental illness and their carers through such global efforts.
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