Country Choice Final

CHAPTER 15

15.1 INTRODUCTION Although in some cases behavioral and psychiatric/mental are grouped under the same broad category, behavioral health problems are generally effectively treated on an outpatient basis with combination psychotherapy and pharmacotherapy (medications). Behavioral health professionals are licensed by the state in which they reside to practice, and they collaborate on the management of clients’ behavioral problems. These professionals include psychiatrists, psychologists, psychiatric nurse practitioners, social workers, family counselors, and drug/alcohol and mental health counselors (Parker, 2002). Such chronic problems as dementia and mental retardation are considered psychiatric/mental problems rather than behavioral.

There is a distinct interconnectedness between mental health and health in general. The WHO defines health as, “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity” (WHO, 2001b, p. 1). Mental health on the other hand is defined as, “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stress of life, can work productively and fruitfully, and is able to make a contribution to his or her community … it is determined by socioeconomic and environmental factors and it is linked to behavior” (WHO, 2001a, p. 1; WHO 2010, p. 1). For example, people are generally resilient enough to spring back when they are stressed, or depressed and are therefore able to maintain their

baseline. However, when they lose their resiliency and remain stressed or depressed for long periods and are unable to cope, they become ill.

Globally, the prevalence of mental disorders is high (approximately 80 percent), yet few severely affected seek treatment (Demyttenaere, et al., 2004). Kleintjes, Lund, and Flisher (2010), in their analysis of mental health in children and adolescents across the four African countries studied, which included Ghana, found that stigma toward people with mental health problems was felt to contribute to active discrimination and the violation of the human rights of service users; whatever their age (p. 136). Respondents viewed this as significantly influencing their “willingness to disclose and seek help” (p. 136). The authors also found that “there is a low priority of mental health relative to other health programs; and there is a link between poverty and mental health” especially in regard to development of problems such as “stress, depression and anxiety” (p. 137).

To the extent that a persons’ mental health is intact, they are more capable of maintaining their physical and social well-being. If their physical health is poor, or severely threatened by disease and the ills of poverty, it can negatively impact their mental and behavioral health. Herrman, Saxena, and Moodie (2005) suggest that physical illness is detrimental to mental health just as poor mental health is detrimental to physical health. Perhaps the more complex the physical health problem, the more likely a behavioral health problem will emerge. The same can be said for social problems and pressures that may result in risky behavior that consequently results in physical, mental, or behavioral health problems.

15.2 BEHAVIORAL HEALTH When persons have diminished capacities—whether cognitive, emotional, attentional, interpersonal, motivational, or behavioral…that interferes with their enjoyment of life or adversely affects their interactions with society and the environment, they are considered to have a mental health disorder (Kirby, 2004, Report 1 p 68). Mental illnesses not only result in human suffering for the individuals experiencing the problem but it also affects their families, the healthcare system, the social system, the workplace, and society at large (IHE, p. 9). According to the WHO (2004) mental health problems present a global burden and in some countries it carries a stigma that impedes how communities address the problem. Further, not only are “mental health problems stigmatized in society globally, mental health is generally underfunded, and it presents a significant burden for countries throughout the world” (WHO, 2003, p. 18). The WHO also predicts that “by 2020 mental disorders will account for 15% of disability—adjusted life-years lost to illness” (p. 18).

Worthington and Rauch (2000) suggest that behavioral therapy consists of reconditioning patients’ behaviors or the associations they have between a stimulus and response. Behavioral health, in much of the world, is an all-inclusive term that refers to the management of community-based, emotional instabilities, as well as psychiatric mental health problems that do not require hospitalization. It includes a variety of problems that can be managed on an out-patient basis, and emphasizes changing behavior. For example, according to Worthington and Rauch, (2000, p. 1147), “anxiousness is a normal human, or behavioral response to stress. However, distinguishing it from pathologic anxiety and anxiety disorders often requires a systematic evaluation and a thorough understanding of the individual patient’s physical and psychological status. Unrecognized and untreated, anxiety disorders increase the cost of medical care and render patients vulnerable to further morbidity, including demoralization, hypochondriasis, depression, and varying degrees of disability. A comprehensive and empathic assessment of the anxious patient by the primary care physician permits a reasoned and often therapeutically effective approach to the difficult problems presented,” by introducing behavioral interventions at the earliest point of contact (the community).

15.3 PREVALENCE AND MANAGEMENT OF BEHAVIORAL HEALTH CARE IN INDUSTRIALIZED (DEVELOPED) COUNTRIES

Behavioral and Mental Health in the United States It has been well established, that access to delivery of high quality, affordable health care in the United States health delivery system is generally a problem (USDHHS, 2006; Long, Chang, Ibrahim, & Asch, 2004; Burroughs et al., 2002; Smedley, Stith, & Nelson, 2002: Exner et al., 2001). However, access to behavioral health care and services in the United States (U.S.) is an even greater challenge. It has obvious shortcomings. According to the CDC (2007), 1 in 2 Americans in the United States has a diagnosable mental disorder each year, including 44 million adults and 13.7 million children. Although 80–90% of mental disorders are treatable, of those with a diagnosable mental disorder, fewer than half of the adults actually get help and only one-third of children get help. The CDC also reports that in 1999, suicide was the 8th leading cause of death in the United States. In 2009, suicide dropped to the 10 th leading cause of death (CDC, 2010). However, since 1980 suicide has doubled among young African American males. Further, African Americans are more likely to experience a mental disorder than their European American counterparts, yet they are less likely to seek treatment. When they do seek treatment, they are more likely to receive inpatient care. Latino American women are more likely to suffer from depression than Latino men, and when Asian American/Pacific Islander females seek mental health care, they are more likely to be misdiagnosed as “problem free” (CDC, 2007). Finally, American

Indians/Alaskan Natives appear to suffer disproportionately from depression and substance abuse and they are overrepresented as hospitalized in-patients compared to European Americans (CDC, 2007).

The Public Health Act of 2000 defines the function of the National Institute of Mental Health (NIMH) and the Center for Mental Health Services (CMHS). The Children’s Health Act of 2000 authorized the Substance Abuse and Mental Health Services Administration (SAMHSA). Patients who have documented addiction to controlled substances qualify for governmental disability payments. There are 7.7 psychiatric hospital beds per 10,000 of the population, and 3.1 beds in psychiatric hospitals in the United States. There are also, according to the WHO, 13.7 psychiatrists per 100,000 in the population (WHO, 2005). Feldman, Bachman, Cuffel, Friesen, and McCabe (2003) assert that there are 14.2 psychiatrists per 100,000 population. Both are substantial numbers. There are also 6.5 psychiatric nurses, 31.1 psychologists, and 35.3 social workers (WHO, 2005). ( who.int/profiles_countries , 2005).

The National Health Reform Bill (the Obama Bill), although heavily pertaining to physical health, does encompass limited considerations for mental health. There are an array of social, psychological, and biological factors that determine a person’s mental health and stability. Any one of these determinants can threaten a person’s mental health. A good example of this is evidenced by the stressors of such things as poverty, violence, and poor working conditions (WHO, 2010, p 2). Laypersons often do not understand the distinction between behavioral health and mental health.

The essential levels of care covered by the United States’ healthcare insurance policies are similar to general healthcare coverage. Despite a move decades ago toward deinstitutionalization of mental health services, resulting in the closure of many long-term mental healthcare facilities across the country, few changes have occurred in the funding of mental health. Also, due to the lack of community-based mental health providers, access to community-based mental health services are somewhat limited.

In the United States, behavioral health covers an array of disorders such as alcohol and other mood altering substances abuse and dependence, anxiety, depression, chronic fatigue, chronic and/or nonmalignant pain, insomnia, obesity, sexual dysfunction, and phobias (Worthington & Rauch, 2000). Phobias, according to Worthington & Rauch (2000) are “irrational fears related to specific stimuli that often result in an anxiety response that interferes with some aspect of people’s ability to function” (p. 1148). Behavioral health also may include the management of people considered bipolar, relationship violence, and adolescent adjustment problems that could include bullying, which schools often fail to prevent and parents often feel helpless against.

The prevalence for many behavioral health problems are high, yet behavioral health provider availability in the United States is low. For example, anxiety disorders have an estimated lifetime prevalence of 25% in the general population, and account for frequent visits to the non-psychiatric provider (physicians and nurses in advanced practice roles such as NPs and CNs). “Evaluation and management of these patients are often challenging because they present with feelings of distress and concern about disease in the absence of objective evidence” (Worthington and Rauch, 2000, p. 1147). Goroll and Mulley (2000) suggest that, “patients with anxiety disorders are 50% more likely to be alcoholic; similarly, the prevalence of anxiety disorders is 50% higher in alcoholics” (p. 1149).

An important message from the AMA suggests that, “alcohol use and abuse is the major cause of preventable deaths associated with violence and motor vehicle accidents. Excessive alcohol intake strains personal relationships and may affect one’s ability to keep a job, and it results in serious health problems including damage to the liver and brain” (Ringold, 2005 p. 1).

The most recent available national prevalence data on alcohol abuse and dependence is from 2000 and 2001. These data suggest that the United States has a very high prevalence of alcohol abuse and dependence, approaching 8% or nearly 14 million adults. The rates of abuse and dependence among persons 18–29 is twice those for the nation as a whole and alcohol use among 12- to 17-year-olds has drastically increased (NIH, 2009, p.1; Hanna, 2000, p. 1169). The CDC (2007) reported that overall, 6 in 10 (61.2%) of U.S. adults were current drinkers in 2005–2007 (CDC, p. 1).

During 2006–2009, the National Institute on Alcohol Abuse and Alcoholism (NIH, 2009) obtained data on alcohol use from surveying 44,000 children between ages 12 and 14 across geographical and socioeconomic areas. Reportedly 5.9% of 12- to 14-year-olds admitted to using alcohol during the month prior to the survey. Almost all of these kids got the alcohol for free, 45% reported getting their alcohol from a parent or other family member or taking it from their home without permission (NIH, 2009). Additionally 5,000 youths and teens under the age of 21 die annually as a result of underage drinking. These deaths include deaths from falls, burns, and drowning. Young people who use and abuse alcohol are also more likely to perform poorly in school, and engage in risky sexual and drug taking behavior (NIH, 2009).

In 2000, the overall estimated alcohol related cost to society associated with lost productivity, crime, accidental deaths, and fire exceeded $165 billion. The estimated direct cost of alcohol treatment and medical consequences of using and abusing alcohol approached $20 billion. More than $15 billion is paid for medical care alone (Hanna, 2000, p. 1169).

Primary care physicians are uniquely positioned to detect and treat harmful patterns of alcohol use. They are also best positioned to prevent alcohol related disorders and a host of related medical and social problems. Screening for alcohol problems long before they become disabling and more difficult to manage should be a routine part of every primary care practice. Timely recognition and intervention is critical. Alcoholism encompasses two distinct conditions; alcohol abuse and alcohol dependence (Hanna, 2000) commonly referred to as alcohol addiction. When persons become addicted to alcohol it greatly impacts not only their lives but the lives of their families, their co-workers, and their community. Once addicted, long-term family counseling, the use of support groups, detoxification, and substitution therapy is often necessary.

Depression is a complex problem that presents clinically as a variety of psychological and physical complaints. It is often not diagnosed early, and sometimes goes undiagnosed. Although many persons become occasionally depressed for short periods they are generally resilient and spring back before long. When depression is unresolved, it is called clinical depression. At this point it requires intervention and follow up that often includes the use of antidepressant medications and professional counseling.

Access to mental health services in the United States is based largely on insurance provisions which vary among subscribers. There is coverage under Medicare and Medicaid for individuals who are considered poor. In most cases, out-patient psychiatric mental health and behavioral health services have limited insurance coverage. Also, there are so few community-based behavioral health providers in some geographic localities that services are not available, and existing programs are limited; others are even threatening to close. As a consequence, primary care providers are among the first to evaluate and treat persons with behavioral health problems. However, referrals to behavioral health providers are difficult to obtain, and when they can be made wait lists are very long.

Behavior health managed care companies have reported that major segments of the U.S. population lack access to clinicians who are capable of properly evaluating the indication for prescribing and monitoring psychotropic medications (Christian, Dower, & O’Neil, 2007). With 14.2 psychiatrists per 100,000 people in the United States, a declining number of psychiatric mental health nurse practitioners, and persistent treatment barriers, Feldman et al. (2003) predict there will be continued lack of access to treatment and fewer incentives for behavioral health providers to enter into community practice.

Healthy People 2010 and 2020 call for more mental health providers to treat individuals in need of behavioral health. According to the United States Department of Health and Human Services (USDHHS) many employers of large workforces have established the goal to improve delivery of

behavioral health care in general medical and mental health sectors (United States Department of Health and Human Services, 2007). The Substance Abuse and Mental Health Services Administration, the largest supporter of mental health grant opportunities for mental health innovation and demonstration programs recognizes the need for more community-based mental health research designed to assist providers in better responding to behavioral health needs at the community level. This organization actively advocates for increased numbers of mental health providers who are experienced in, and committed to, evidence-based practice to be community-based, rather than hospital-based (United States Department of Health and Human Services, 2007).

Although behavioral health is generally underfunded throughout the United States, some states are leading the way in behavioral health services to address the needs of children. One such state is New Mexico where access to behavioral health care and services for children and their families is a state priority. Bolson (2004) describes the New Mexico mental health system as one that utilizes state and federal funds to develop and maintain a statewide coordinated, comprehensive service delivery system that has three distinct characteristics. It is: flexible and designed to meet the needs of clients at the local level; inclusive of, and responsive to, the ethnic, cultural, racial, and socioeconomic diversity of the state; focused on results with clearly defined and measurable outcomes for the clients served (p. 4).

The Child Youth and Families Department (CYFD) of the Community Services Section of the Children’s Behavioral Health and Community Services Bureau is a very successful program. It disseminates an extensive, service delivery manual that fully describes and defines the standards and guidelines to be followed for children receiving behavioral health services. The CYFD’s goal is to improve and enhance the emotional, mental, and behavioral health of its children, youth, and families. Children are, without question, the clearly identified (service) population that includes youth up to age 21 (and their families) who have an open case file with one of three agencies that make formal referrals for services. These include, County Protective Services, the Juvenile Probation/Parole office, and the Tribal/Social Services. Children determined to be at risk for entry into CYFD’s Protective Services, Juvenile Justice System, and/or Tribal Social Services can also be referred for behavioral health services. According to Bolson (2004), specific contributing factors defining the population meeting the specific service categories include:

• Severe behavioral, emotional, neurobiological problems/disorders or at risk of developing such problems

• Intention/plan to hurt self or others as evidenced by written, verbal, and/or behavioral indicators

• Child or parent suicide attempt during the past year

• Substance abusing behaviors by child or their parents

• Multiple delinquent acts or law enforcement contacts by child

• Multiple school problems, including suspension or expulsion from school during the last year

• Homeless/runaway

• Child or parent with mental illness

• Parents who are incarcerated, involved with the criminal justice system, or on parole or probation

• Physical, sexual, emotional abuse or neglect of the child (current or known history)

• Multi-generational history of familial maltreatment, neglect

Smith and Sederer’s (2009) proposal of a “mental health home” is another interesting, yet feasible solution to addressing the needs of the homeless who have serious mental illness. As a consequence of their illness, the mentally ill homeless, failing to get access to care at the community level, are bounced from place to place. They often become incarcerated, and have repeated admissions to hospitals to address mental health crises that, with treatment, may have been prevented. The “mental health home” concept is based on an earlier “medical home” concept, primary care’s solution to accessible and accountable services for persons with chronic medical problems. The authors justify the need for mental health homes suggesting that they will provide well-coordinated, integrated primary and preventive care, recovery orientation, evidence-based practices, and family and community outreach (Smith and Sederer, 2009).

Behavioral and Mental Health in Canada Mental illnesses indirectly affect all Canadians through illness in a family member, friend, or colleague. The onset of most mental illnesses occurs during adolescence and young adulthood, and it affects people of all ages, educational and income levels, and cultures. Mental illnesses are costly to everyone (individuals, families, the healthcare system and the community). In 1993 the economic cost of mental illness was estimated to be $7.331 billion. Further, the stigma attached to mental illnesses presents a serious barrier perhaps best seen by how it impedes diagnosis and treatment and also lack of acceptance in the community (publichealth.gc.ca).

Canada’s policy on mental health services dates back to 1988. The major policy components were, and still are, typical of the policies of most developed countries. These components are advocacy, promotion, prevention, treatment, and rehabilitation (WHO, 2005). Canada has 13 interlocking health insurance plans in 13 separate service delivery systems. Although the figures are somewhat dated (1991–1993) the total number of hospital beds per 10,000 in the population was 19.4. Of these, 9.1 were designated as beds in psychiatric hospitals. The number of psychiatrists per 100,000 population was 12, the number of psychiatric nurses was 44, and psychologists 35 (WHO, 2005). Eighty-six percent of hospitalizations for mental illness in Canada occur in general hospitals. The majority of these hospitalizations are due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders, and suicidal behavior (publichealth.gc.ca).

Mood disorders, anxiety disorders, schizophrenia, personality disorders, and substance use disorders are among the problems that are responsible for the leading source of human mental disability in Canada (Kirby, Report 1, 2004, p. 68). The growing burden of mental illness in Canada in relation to utilization of healthcare resources, lost productivity, and human suffering has been well documented (Global Business and Economic Roundtable on Addiction and Mental Health, 2004; Health Canada, 2002; Romanow, 2002; Wilkerson, 2006).

One of the fundamental things a country must do before it can determine the amount needed to be spent on mental health is to have comprehensive estimates of the prevalence of mental health disorders in that country (IHE, 2008, p. 15). Prevalence data are used to estimate the proportion of a population that is suffering from an illness or disorder. Epidemiological studies have estimated that 21% of all Canadians will experience a mental illness or addiction in their lifetime (lifetime prevalence), while 3% will suffer a severe persistent disability (Health Canada, 2002). The highest prevalence of mental illness occurs among both men and women between ages 35 and 49. Canadian women have a 1.5–2 times higher prevalence rate than Canadian men for both diagnosed and undiagnosed populations (IHE, 2008, p. 12). The most common mental illnesses among Canadian adults are anxiety disorders which account for 12%, and mood disorders accounting for 9%. Another 6–9% of adult Canadians suffer from personality disorders (IHE, 2008, p. 10). Schizophrenia affects less than 1% of the Canadian population (Kirby, Report 1, 2004, 1, p. 85).

“It is estimated that 37% of Canadians experience some type of mental health problem. As a result of the migration process, many immigrant and refugee women suffer serious mental illnesses such as depression, schizophrenia, post-traumatic stress disorder, suicide and psychosis” (Donnelly et al., 2011, p. 2790). In 2003, approximately 1.9 million (7%) adult Canadians were diagnosed with mental disorders such as a mood or anxiety disorder or schizophrenia. It is estimated that another 1.6 million (6%) of adult Canadians with mental disorders went undiagnosed (Lim, Jacobs,

Ohinmaa, Schopflocher, & Dewa, 2008). People with undiagnosed mental illness include those individuals who may have self-reported, those in poor mental health, those being seen by two or more mental health professionals, those who are seriously depressed, and those having had seriously considered suicide but none actually received a diagnosis of mental illness from a physician.

Approximately 50% of Canadians who suffer from severe mental illness develop alcohol or other drug abuse problems at some point (Alberta Mental Health Board, 2004, p. 4; Adlaf, Begin, & Sawka, 2004). Suicidal behavior is often a symptom of mental illness and addiction. Each year approximately 3,700 Canadians commit suicide and more than 90% of suicide victims have a diagnosable mental illness of substance use disorder (Kirby Report 3, 2004, p. 27; Langlois & Morrison, 2002). According to Clayton and Barcel (1999), there was an estimated mean economic cost per suicide death of almost $1 million (in 2006 dollars). Also, of the 3,700 Canadians committing suicide every year, Canada suffered an estimated premature mortality cost in 2006 of approximately $3.7 billion (IHE, 2008 p. 17).

Using the WHO’s Global Burden of Disease measure, the Disability-Adjusted Life Year (DALY) expresses years of life lost (YLL) to premature mortality (due to suicide in cases of mental illness). It also expresses years lived with a disability (YLD) of specified severity and duration. One DALY is one lost year of healthy life. In order to calculate the total DALY for a given population, the YLLs and the YLDs for that condition is estimated and summed separately. The DALY as a health status indicator extends the concept of potential years of life lost (PYLL) due to premature death to include equivalent years of healthy life lost to disability (WHO, 2001).

The disease burden for behavioral health problems has progressively increased over several years. For example, measured in DALYs, neuropsychiatric conditions accounted for 10.5% of disease burden worldwide in 1990; 13% in 2002, and it is estimated to increase to 15% by 2020 (IHE Report, 2008, p. 13). Mathers & Loncar (2006) predict that unipolar depression, although the fourth leading cause of disease burden in 2002, is anticipated to become the second leading cause worldwide by 2030, outranked only by ischemic health disease. Further, in developed (industrialized) countries not only is unipolar depression projected to become the leading cause of disease burden by 2030, Alzheimer’s disease, other dementias, and alcohol use disorders are also projected to be among the top four causes of disease burden (p. 13). Considering the disability component alone, Global Burden of Disease 2002 estimates that neuropsychiatric conditions accounted for 31.7% of all years lived with disability (YLDs), and unipolar depression was the leading cause of disability worldwide, accounting for 11.8% of the total TLDs (WHO, 2002):

Factoring in the direct costs for social care, hospital services, physician services and pharmaceuticals, the cost of treating and caring for mental health services in Canada

exceeded $7.7 billion in 2006. This includes payments made by the Ministry of Health, Housing and Education, private insurance and out-of-pocket payments made directly by consumers (Jacobs et al., 2008). The indirect costs estimates are considerable (between $6.2 billion and $9.1 billion) during this same period, accounting for loss in work including short- and long-term disability. Because of the greater prevalence of mental illness during mid-career periods, this loss of productivity usually affects ages 36–55 (IHE, 2008, p. 15 & 16). Access to services is free including medications, hospitalization and treatments.

Many agree that investment in community-based services and support for such initiatives as safe and supportive housing can reduce other costs such as funds appropriated to combat crime, unemployment, poverty, and homelessness (Toronto-Peel Mental Health Implementation Task Force, 2002; Alberta Mental Health Board, 2004).

Loss of income and independence, and fear of being stigmatized may strongly influence whether a person with a behavioral problems seeks treatment. It may also affect whether the person adheres to the prescribed regimen, or, if treated, how effectively s/he reintegrates into the community after crises.

Behavioral and Mental Health in Japan Japan is credited with having one of the lowest (4%) mental illness prevalence rates in the world, second only to Italy (0.5%) (Wilkinson & Pickett, 2007). However, the most common mental disorder in Japan is depression. The Ministry of Health is the core structure under which mental health services are provided in Japan. Prior to World War II, The Confinement and Protection for Lunatics Act of 1900, and The Mental Health of 1919 was all that existed. Japan has had a Mental Health Plan since 1950, and a Substance Abuse Policy since 1953 (WHO, 2005).

The 1950 Mental Hygiene Law allowed for compulsory institutionalizing of patients with mental problems. This law was revised in 1987 after two inpatient deaths occurred resulting in human rights initiatives for patients and a movement toward community care and rehabilitation (WHO, 2005). The revised law, which is reviewed every five years, emphasizes advocacy, promotion, prevention, treatment, and rehabilitation. In 1995 government plans were revealed for what was called “The Plan for People with Disabilities” which positioned Japan for normalization which focuses on community-based care for persons with mental illness. The most recent amendment to this legislation, in 2000, provided public funding support and exempted the family and patient of any responsibility for damages caused to self or others while the patient was being treated (WHO, 2005).

Since 1990, Japan has made significant attempts to address mental health in similar ways to other countries in the industrialized world. Mental health care is part of Japan’s Primary Healthcare System. However, persons with severe mental disorders have no community options; rather, they are forced to use psychiatric emergency services (WHO, 2005). Japan places great emphasis on what is called normalization , which requires viewing mental illness as a disability and encouraging the integration of psychiatric inpatients into the community (Ito and Sederer, 1999; Nakatani, 2000).

Japan’s expenditure on mental health is 0.5% of its GDP, a relatively small percentage of their total health expenditure (Ministry of Health, 2000), and it is 5% of its total healthcare budget. Primary funding sources, in descending order, are taxes, social insurance, out-of-pocket by family or patient, and private insurance (WHO, 2005). If a person is hospitalized for mental health treatment, Japan’s payment structure favors shorter hospital stays and initiating community-based care as soon as possible. Individuals with mental disorders receive disability payments.

Japan has 28.4 psychiatric beds per 10,000 in the population. There are 20.6 specifically in mental hospitals. The number of psychiatric beds (with a 95% bed occupancy rate) is the highest number in the world, and is three times the number in the United Kingdom. The majority (89%) of psychiatric beds in Japan are in the private sector. There are approximately 1,250 facilities in Japan that offer day and night care for patients with behavioral and mental problems.

Mental health workers in Japan include psychiatrists, psychologists, general practitioners, therapists, social workers, and various levels of specialist nurses. Per 100,000 in Japan’s population, there are 9.4 psychiatrists, 59 psychiatric nurses, 7 psychologists, and 15.7 social workers. The Japanese healthcare system has more than enough psychiatrists (13–23 times more than the number in Iraq and the Philippines) although many are not community-based. However, there are inadequate numbers of other mental health staff who are adequately trained to provide community care. This has slowed Japan’s progress toward achieving its deinstitutionalization policy.

Although, Japan’s focus is on community-based mental health services, mental health primary care workers are not rigorously evaluated so it is difficult to assess performance outcomes (Tsuchiya & Takei, 2004). There is also little published data on treatment efficacy and training of community-based providers of mental health services making it difficult to determine effectiveness of care and services. Although Japan’s Ministry of Health allocates ample resources for research and monitoring of its mental health system including patient’s rights and getting feedback from patients about quality of mental health care, (Hamid, Abanilla, Bauta, & Haung, 2008, p.469) this is an area in need of growth. The updated national data-base that has been useful in guiding their

existing mental health policy and evaluating new policies (Hamid et al., p.469) is fully operational, although it is difficult to determine its full value.

There are specific programs in Japan to address disaster-affected populations, older adults, and children. For example, a ten year “Gold Plan” to promote health care and welfare for the Elderly has been in place since 1987. The Plan was revised and launched as, “Gold Plan 21” in 2003. There is also a Zero Physical Restraint Campaign (WHO, 2005).

Japan has been hit by devastating, life-changing natural disasters that have greatly impacted the general health and mental health of massive numbers of people. For example, the long-term health challenges resulting from the nuclear crisis in Fukushima in the aftermath of Japan’s March 11, 2011 earthquake followed by the devastating tsunami, may never be fully understood. For tens of thousands of people who lost their loved ones, hundreds of thousands who lost their homes and their livelihood, compounded by the associated stress (Kennedy & Luthra, 2011) life as they knew it will never be the same. The full impact of this natural disaster on the mental health of all involved—survivors and responders—may never be known. It is suspected that prevalence of such problems as anxiety and depression will likely increase. Francesco Checchi, epidemiologist at London School of Hygiene and Tropical Medicine, stresses the importance of reinforcing public health surveillance of mortality and a number of other problems, including mental disorders as well as suicide (Kennedy and Luthra, 2011), expecting the incidence and prevalence to escalate. This is of particular importance as Japan already has a relatively high incidence of suicide.

According to the Organization for Economic Cooperation and Development (OCED), “ in 2005, 140,000 people in OECD countries took their own lives, equating to 12 per 100,000 population…the rates were highest in Korea, Japan, and Hungary, at 19 or more deaths per 100,000” (OCED, 2008, p.3). Further, “although some countries have seen declines in their suicide rates of 40% or more in recent decades, Korea and Japan have seen significant increases” (OCED, 2008, p. 3).

Japan is one of the richest, healthiest countries on earth, with a vast capacity for disaster response (Kennedy & Luthra, 2011). It has an excellent record of tracking the effects of crises dating back to the 1945 atomic bomb crisis. Despite this, the enormity of the potential disaster-related mental health challenges of the 2011 earthquake and tsunami, may have far reaching implications.

Behavioral and Mental Health in the United Kingdom Reference in the literature to the utilization of mental health services in the United Kingdom (UK), with the exception of England, is either inconsistent, or lacking. Although Scotland had a Mental Health Services Framework in 1997, referred to as “Our National Health: A Plan for Action, A

Plan for Change,” 2000; and Northern Ireland published its plan, “The Way Forward for Northern Ireland,” in 1995, there were no overall UK mental health policies in place until 1998.

Delivering race equality (DRE) in mental health care prompted the change in mental health policies in the UK. The DRE was a five year action plan, that was an initiative launched for the purpose of improving services for minority ethnic communities. This emerged in a response to a report of the independent inquiry into the death of an African-Caribbean patient who died in 1998 in a medium-secure psychiatric unit after being restrained by staff ( dh.gov.uk.en , 2007).

These policy frameworks, called National Service Frameworks (NSFs) were specifically designed to improve particular areas of care including mental health. The National Service Framework for Mental Health identifies key interventions representing nationally-arrived-at standards for the purpose of raising the overall quality of mental health care and services in the UK. By standardizing quality and decreasing variation in care (Boyle, 2008), actions such as utilizing standard treatment protocols and performance expectations should maximize the quality of mental and behavioral health care. Efforts are also made to increase efficiency of, especially, social care (Boyle, 2008). Social care includes a range of areas, such as living accommodations, employment, and training.

The typical UK mental health policy focuses on primary care, access to mental health services, and it especially addresses providing effective services for people with severe mental illness. It also provides services for caregivers and initiatives to reduce suicide. The UK’s National Health Framework for Mental Health of 1999, and England’s National Health Service (NHS) Plan for 2000, both addressed mental illness. England’s NHS focuses on three major priorities geared more toward interventions and care that is more responsive to the needs of the mentally ill, rather than those in need of behavioral health. The priorities included firstly, that all in crisis will have access to crisis resolution/home treatment teams by 2005. Secondly, by 2006, all with a first episode psychosis will have access to intensive treatment from early intervention teams for the first three years. Finally, all with intensive needs will have access to assistive outreach teams by 2004 (WHO, 2005). One piece of the UK’s mental health legislation covers England and Wales; a second piece covers Scotland, which is historically different from the English legislation; and a third covers Northern Ireland.

Although mental health policies were generally not enacted in the UK until 1998, disabled persons received partial coverage under several initiatives. The Disability Discrimination Act of 1995, seeking to end discrimination that many disabled persons were faced with, provided some coverage for the mentally disabled. This Act provided new rights for the disabled to access goods, facilities, services, and employment, as well as buying and renting property. The Disabled Living

Allowance was also provided as an extra-cost, non-contributory benefit that was unrelated to income coverage. Department of Social Security welfare benefits also provided for persons with documented, longstanding disabilities ( who.int/mental_health ). The most recent Disability Discrimination Act of 2005 amended the definition of ‘mental illness’ by removing the requirement that conditions be “clinically well-recognized.” This enabled persons not already diagnosed by a doctor with well known conditions such as anxiety, depression, bipolar disorder, and schizophrenia to also be covered ( opsi.gov.uk , 2005).

The overall prevalence of mental health disease in the UK is 23%. Depression and anxiety are among the most common mental health problems in the UK (17.5%), psychosis is 0.5%. There have been very few changes in the overall prevalence of mental health illness in England’s healthcare system from 2002–2009 (Singleton, Bumpstead, O’Brien, Lee, & Meltzer, 2001, McManus, Meltzer, Brugha, Bebbington, & Jenkins, 2009).

Actual mental health services in the United Kingdom are covered under the National Health Service which provides free universal coverage for everyone at the point of use that often begins with the general practitioner. Although there are slight variations among countries, the free coverage generally includes medications, hospitalization, and other treatments. Access to mental health services is generally at the primary care level. Based on beds per 10,000 in the population, the total number considered psychiatric beds in the UK is 5.8. There is no differentiation between beds in psychiatric hospitals compared to those in general hospitals. Psychiatrists per 100,000 in the population number 11, psychiatric nurses number 104, psychologists number 9.0, and social workers number 58 (WHO, 2005).

The UK spends 10% of its health budget on mental health. Primary sources of funding come first from taxes, then private insurance, social insurance, and finally out of pocket expenditures are paid only if needed. Approximately 85% of expenses for health and social care of the mentally ill are paid by the NHS; whatever remains is covered by local authorities ( www.dh.gov.uk ). The Ministry of Health is the core structure under which mental health services are provided. Among the various departments falling under the administrative structure of the NHS’ Ministry of Health, two are most immediately responsible for mental health. These are the Commission for Social Care Inspection and the Mental Health Act Commission. These two merged into one entity in 2008 ( www.dh.gov.uk ).

Early intervention is critically important in preventing severe mental illness. England has made some progress in addressing early intervention in psychosis (EIP) by linking with primary care providers to facilitate early diagnosis and referral, and linking with public service organizations, schools, universities, and the welfare and criminal justice system (Boyle, 2011). Although mental

health problems present a significant burden of disease throughout the UK, it is best demonstrated by the economic and social burden in England (Sainsbury Centre of Mental Health, 2003a).

The economic and social costs of mental health problems in England were £77.4 billion in 2002–2003. Using the sample formula, the aggregated cost of mental health care in England was estimated to rise to £105.2 billion in 2009–2010 (Sainsbury Centre for Mental Health, 2003a). The sample formula is used to calculate the cost of EIP. This formula is based on the expectation that clients remain with services for 3 years, at an estimated cost of £5,000 per person, and it factors in a minimum cost at years 1, 2 and 3. The cost at year 3 represents recurrent annual cost costs of services Salisbury Centre for Mental Health, 2003a). The total cost of mental health care by category of costs for 2002–2003 includes £12.5 billion for health and social care, £23.1 billion for output losses generally occurring as adverse effects of mental illness resulting in the inability to work, and an additional £41.8 billion (54.0%) for human costs including things that negatively impact the quality of life. The predicted cost by category for 2009 –2010 is £21.3 for health and social care, £30.3 billion for economic output losses, and £53.6 (51.0%) billion for human suffering (Sainsbury Centre for Mental Health, 2003a).

The key findings in an Office for National Statistics (ONS) survey examining prevalence of mental health problems in populations 16 to 74 years old living in private households across Britain and England, were that 1 in 6 (16.5%) of the population exhibited symptoms in the week prior to interview sufficient to warrant a diagnosis of a common mental health problem, with women exhibiting higher rates than men overall; London had a slightly higher rate than England in general (18.2% compared to 16.5%); and England had the highest rate of depressive disorders (London Health Observatory, nd., p. 2).

In Wales, for example, there is a Mental Health Foundation that has worked with the Welsh Assembly to inform policy and improve mental health services there. Through their consultant efforts, they have witnessed improvement in user and caregiver service involvement across Wales (Mental Health Foundation, 2012).

Behavioral and Mental Health in France France has had a National Mental Health Program in place since 1985. They also have a comprehensive national suicide prevention program and most recently, a program designed to prevent depression that is called, “Actions Against Depression.” Among France’s latest initiatives addressing mental health is a policy on the admission of patients to psychiatric hospitals under constraints (WHO, 2005). Sectorization, a concept dating back to World War II, where one team is responsible for both inpatient and outpatient care of persons within its parameters, is a concept that still exists. Of the approximately 1,000 sectors in France, there are different sectors for adult,

adolescent, child, and forensic psychiatry that encompass community care and sheltered workshops (Jaeger, 1995).

The primary source of mental health funding in France is from social insurance. Funding of mental health in France is less dependent on taxes. France spends approximately 8% of its total health budget on mental health. With the exception of services by private sector psychologists and psychoanalysts, patients have free access to private or public mental health professionals of their choice. However, in the event that the patient is severely mentally ill or severely deprived financially, there is full coverage without cost. There is also special coverage and allowances for housing if the patient is disabled patient (WHO, 2005).

Mental health in France is part of the primary healthcare system with treatment of severe mental disorders provided at the primary care level. There is regular training of primary care professionals. The total number of psychiatric hospital beds per 10,000 in the population is 12. There are 22 psychiatrists per 100,000 in the population, 98 psychiatric nurses, and 5 psychologists (WHO, 2005). There is an urban rural service divide in France as the majority of psychiatrists and psychologists practice in the large cities, leaving somewhat of a void in the rural area where the few practicing mental health providers are backed up. Medical students pursuing clinical rotations in mental health are discouraged and even prevented from specializing in psychiatry. Psychiatric diagnoses of adults are made according to ICD-10 criteria, but patients younger than 20 years old are still categorized according to the French classification of child psychiatry (WHO, 2005).

France also has specific mental health programs for disaster affected populations, older adults, and children. In 2001, a program was launched to campaign against stigmatizing mental illness, and to reinforce patient rights, improve professional mental health practices, and improve prevention, rehabilitation, and community psychiatry (WHO, 2005).

Most high income countries have not conducted national or regional surveys that address mental health service use, access to care, and unmet needs (Alonso et al., 2004). The findings in one study that sought to determine use of mental health services in six European countries, including France and Italy, used odds ratio (OR) estimates, and their estimated (95%) confidence intervals (CI). Data were reported regarding how frequent individuals sought medical consultation. The most frequent consultations were reported to be among individuals with mental disorders. The rate of mood related consultations was reported as (36.5%, 95% CI 32.5 – 40). One third of the consultations were made with mental health professionals only (mostly psychiatrists rather than psychologists or counselors). These data suggest there is insufficient use of health services for mental disorders in Europe and a need for improvement. The most important factor associated with the use of health

services was the presence of a mental disorder, particularly a mood disorder. There was a peak in use of services in females between the ages of 35 and 49 (Alonso et al., 2004).

Behavioral and Mental Health in Italy For over thirty years, and with very few changes in policy, the National Mental Health Reform Act (1978) or Law 180, has served as the legislative framework for Italy’s care of the mentally ill. Spearheaded by the pioneer efforts of psychiatrist Franco Basaglia, Law 180 (commonly referred to as the Basaglia Law) was aimed at ending the institutional abuses suffered by the mentally ill. In Basaglia’s terms, “If mental illness is a loss of individuality and liberty, in the “looney bin” the mental patient can find nothing more than a place where he will be definitely lost, where he will be made the object of his illness and by those who treat him” (Basaglia, 1964, p. 2).

Law 180 called for the closing of psychiatric institutions, and prohibited the referral of new patients to mental hospitals; compulsory admissions (involuntary treatment of patients determined to be dangerous to themselves or others) were permitted only in situations where outpatient interventions were ineffective. The Basaglia Law stimulated the development of community-based comprehensive mental health services. As a result, Italy became the first developed country to care for the mentally ill relying solely on community resources (Lora, 2009).

Under Law 180, deinstitutionalization was more than simply a matter of closing doors; the radical move to dismantle psychiatric institutions symbolized a new way of thinking about addressing mental health problems. Reform was intended to remove the stigma of mental illness as a societal danger, re-educate mental health personnel to exercise more compassion and humane treatment, and to the greatest extent possible, help patients regain their connection to the world outside (Basaglia, 1964). As one observer explains, “The process for the reform of public psychiatric assistance which has taken place in Italy over the last 30 years has resulted in the transition from an asylum psychiatry based on exclusion and internment to a community mental health work-style based on inclusion and the restoration and construction of rights for persons affected with mental disorders” (Del Giudice, 1998).

Administratively, Law 180 establishes the essential levels of care for the mentally ill, and Italy’s 21 provinces are responsible for translating and implementing the mental health guidelines. Drug and alcohol problems are managed outside of the mental health system. Community-based mental health services utilize multi-disciplinary teams (e.g., psychiatrists, psychologists, social workers, nurses) to assist the mentally ill.

A complete network of mental health service in Italy consists of the following components (de Girolamo, Basi, Neri, Ruggeri, Santone, & Picardi, 2007):

• Departments of Mental Health (DMHs) represent the core of the system and are responsible for planning and managing all medical and social resources related to prevention, treatment, and rehabilitation (Lora, 2009, p.7) in defined geographical areas across the country.

• Community Mental Health Centers (CMHCs) are the hub of the community care (Lora, 2009) and manage a large portion of the outpatient and non-residential care through a network of therapeutic and rehabilitative services. CMHCs “provide individual consultations and visits, organize a variety of daytime and domiciliary care activities for the most severely and disabled patients, establish and maintain contacts with other health and social agencies, and provide emergency interventions” (de Girolamo et al., 2007, p. 87). CMHCs are open on a 24-hour, 7-days-aweek basis. Less than 10% of the CMHCs provide overnight care (Lurie, 2008).

• General Hospital Psychiatric Units (GHPUs) provide acute in-patient care and work closely with CMHCs to provide continuity of care. GHPUS are open on a 24-hour, 7-days-a-week basis. By law, hospital units include no more than 20 beds (Lurie, 2008).

• Day Facilities (DFs) provide a range of activities including milieu therapy, vocational skills training, and job placement assistance. DFs are open typically 8 hours a day, 6 days a week.

• Italy has Residential Facilities (RFs) for chronically disabled people who require long term intervention. Frequently, RFs become a second home to a number of patients and resident turnover is low. Residential care includes visits and team based interventions in people’s homes (Lurie, 2008).

Italy’s healthcare system includes coverage of the mentally ill. Access to mental health services is free including medication for major mental disorders. The public health system also covers inpatient psychiatric care but it does not cover outpatient private consultations (de Girolamo et al., 2007). In comparison to the high ratio of mental health spending of the United Kingdom and Luxembourg (12% and 13%, respectively) Italy’s mental health spending, along with Portugal and Spain, is low at an estimated ratio of 3–5% (IHE Report, 2008).

Current estimates for personnel employed by public mental health services include nurses making up nearly one-half of the workforce with psychiatrists and psychologists representing approximately one-quarter of mental health personnel. Statistically, the mental health system is made up of: 14,760 nurses (48%); 5,561 psychiatrists (18%); 1,850 psychologists (6%); 1,551 social worker’s assistants (5%); 2,095 rehabilitation personnel (6.8%). Official information on the large number of private psychiatrists and psychologists is not available (Lurie, 2008; de Girolamo et al., 2007).

According to the European Policy Information Research for Mental Disorders (EPREMED, 2008) the most common mental disorder in Italy is major depression (9.9% of the general population) followed by specific phobia (5.4%) and panic disorder (1.5%).

As a group, anxiety disorders were the most frequent category of mental disorders, particularly for individuals aged 35–64. Alcohol dependency (0.3%) and conduct disorder (0.3%) were less frequent. Women report higher rates of mood and anxiety disorders than men.

A survey (2001–2003) conducted by European Study of Epidemiology of Mental Disorders (ESEMeD), based on a sample of 4,712 Italian citizens, found that “men were twice as likely as women to report an alcohol disorder” (Lora, 2009, p. 7). Reports on the rate of suicide in Italy are conflicting (Girolamo et al., 2007). According to EUROSTAT, for example, the suicide rate in Italy decreased from 7.1% per 100,000 persons in 1996 to 5.9% per 100,000 in 2003, while other data suggest that the rate of suicide in Italy has increased over the past twenty years. Researchers agree that several sociological and cultural factors may affect interpretation of trends in suicide. Perhaps the most significant observation is that worldwide, Italy has one of the lowest rates of suicide (de Girolamo et al., 2007).

Italy’s revolutionary approach to psychiatric reform has resulted in a number of favorable outcomes. Italy has demonstrated that the community-based model of mental health can be successful, particularly in terms of creating access to patients “who in the past might have refrained from any contact with the old-fashioned asylum system” (de Girolamo et al., 2007, p. 88). Statistically, over the past thirty years, the mental health system shows significant growth in treatment capacity (+89%) and accessibility (+243%) for new cases (Lora, 2009). Three years before the reform in 1978, compulsory admissions declined by 50%; by 1994 the percentage of compulsory admissions dropped by an additional 30% (20% in 1984 and 11.8% 10 years later) (Lora, 2009).

Largely due to his belief in work as an important pathway to rehabilitation, Basaglia’s visionary efforts in psychiatric reform led to the development of highly successful social cooperatives, employment situations designed to assist marginalized members of society (e.g., mental patients, the disabled, substance abusers) to transition to the community and the workforce. Passed in 1991, Law 381 provides the regulatory framework for social cooperatives and stipulates that, at a minimum, 30% of the workers must be disadvantaged (Borzaga & Santuari, 2000).

Social cooperatives support the ideal of the community as stakeholders in the rehabilitative process. “In mental health practice, value is increasingly given to diversity, the promotion of connections and exchanges and social co-op strategies” (Del Giudice, 1998). Social cooperatives operate in the public and private sectors and provide a variety of services such as industrial cleaning, laundering

services for hospitals and nursing homes, bookbinding, and hotel management. “By demonstrating that some specific needs can be better satisfied by the production of services, rather than by monetary transfers, social co-ops have helped to transform the Italian welfare system, in that they are better able to create social cohesion. Moreover, many of the services supplied are for the benefit of particularly needy groups (drug addicts, former inmates, and so forth). These services, as well as volunteerism, have also enhanced political awareness of the problems connected with social exclusion” (Borzaga & Santuari, 2000, p. 26).

Innovative strategies, no matter how successful, often involve significant issues that require attention. From a research perspective, one of the most concerning issues raised in the literature is that over three decades there has been only limited monitoring of Italy’s dramatic change to a community care model: “Despite this model’s dissemination throughout Italy and other European and non-European countries, its effectiveness has never been properly assessed” (Monzani, Erlicher, Lora, Piergiorgio, & Vittadini, 2008). Several years of possible lessons and discoveries to improve psychiatric care were lost due to the lack of scientific inquiry.

By 1999 all 76 of Italy’s public mental institutions were shut down (Lora, 2009; de Girolamo et al., 2007). However, the physical closing of mental health institutions should not be confused with success in operationalizing the concept of community-based care. Progress in this regard has been slow and uneven (Lora, 2009; de Girolamo et al., 2007). As observers of the early days of reform suggest, guidelines for deinstitutionalization were general (Lora, 2009) and financing regulations, aimed at efficient health spending and ensuring quality interventions, opened the door to a number of unanticipated issues: “First, it soon became apparent that operational standards were difficult to set in psychiatry, owing to lack of agreement in the definition of diagnostic paradigms and therapeutic approaches” (Piccinelli, Politi, & Barale, 2002, p. 541). As a result, accreditation standards for mental health were based more on organizational and structural criteria such as the number of facilities, and availability of personnel rather than evidence-based practice (Piccinelli et al., 2002). As a decentralized health system, the 21 regions exercise great autonomy in mental health planning and budgeting. Piccinelli et al. (2002) point out the implications of regional discretion and mental health service: “In the absence of operational criteria, each mental health department is not required (by law, at least) to implement a comprehensive set of effective interventions. Apart from drug treatments, which are widely available, psychotherapeutic, and rehabilitation interventions may be based more on the availability, training and cultural paradigms of the personnel than on evidence–based data.” (p. 541).

Community focused care in Italy presents challenges related to the coordination of mental health services including continuity of care, quality of care (e.g., poor prescribing practices) and the availability of specialized mental health services (e.g., services for child and adolescent psychiatry).

Similar to the delivery of health care in general, these issues are strongly tied to the persistent issue of regional differences in service delivery, “… especially between the more wealthy areas of Northern and Central Italy and the poorer Regions of the South and the islands (e.g., Sicily and Sardinia)” (de Girolamo et al., 2007 p. 89). As an example, when it does become necessary to hospitalize a patient, a shortage of public inpatient beds is noted as particularly severe in the south (de Girolamo et al., 2007) with the number of beds varying greatly from the south to the northeast by nearly a 1:2 ratio (Lora, 200). The bed shortage issue affects length of stay. Data reveal the average length of stay in the northeast region as being nearly twice that of the central and southern regions (Lora, 2009). “In regions where public beds are scarce (as in the South) compulsory admissions are almost twice as frequent as they are in other areas of the country, in order to “oblige” hospitals to accept acute patients, at least in some instances” (de Girolamo et al., 2007, p. 86). Italy is recorded as having the lowest rate of inpatient beds in Europe (0.78 public acute inpatient beds per 10,000 inhabitants) and falls below the official national standard of 1 bed per 10,000 inhabitants (Lora, 2009). The low inpatient bed rate raises concerns for patients in acute crisis. Critical attention must be given to expanding the capacity of GHPUs and CMHCs to address this issue (Lora, 2009). An interesting feature of Italy’s bed situation is that Law 180 did not affect private psychiatric facilities which provide over one-half (54%) of the acute inpatient beds (de Girolamo, et al., 2007). “Unfortunately, no reliable systematic data concerning the type and quality of care provided by private psychiatric facilities is to date available” (de Girolamo, et al., 2007, p. 89).

Added concerns for Italy’s mental health system include the need for more attention to family burden in caring for the mentally ill, in other words, providing more educational interventions to help families work through the stress of caring for their mentally ill family members (e.g., feelings of loss, depression, and financial issues). Fioritti (2010) offers perspective on family burden: “Generally speaking, Italian society still relies very much on family links. Some comparative studies (de Girolamo et al., 2007, Fioritti et al., 1997) have shown that over 70% of patients with psychosis live with their family in an accommodation they own and in which they have lived for about twenty years. Patients are usually protected from certain psychosocial stresses (e.g., housing and finance) but quite dependent on significant others, whose involvement in the care process is almost always required” (p. 69).

Additional questions associated with Italy’s reform concern quality of life issues in residential care: the restrictive rules imposed on patient behavior; the high dropout rates among patients with non-psychotic disorders; discharge issues in day care treatment centers (e.g., some patients may be in treatment for three or more years); and the need for more evidence-based practice to improve the quality of mental health care (Girolamo et al., 2007).

Researchers suggest the need to clarify the role of primary care in the mental health system. Deinstitutionalization has increasingly placed the General Practitioner (GP) in the system of psychiatric care. CMHCs tend to focus on the care of the severely mentally ill (e.g., schizophrenia) (Girolamo et al., 2007) while people with common mental health disorders (e.g., depression, anxiety, phobias) are more likely to seek out the GP for help (Berardi, Bortolli,, Menchetti, Bombi, & Tarricone, 2007). In The United States and the United Kingdom, the GP is recognized as having a crucial role in referring patients to mental health services (Berardi et al., 2007). In Italy, however, the scenario is more complicated “since general practice is not organized in a formal primary healthcare service” (Berardi, et al., p.80) and GPs work mostly solo. Further, patients may go directly to a mental health service without a physician referral. Characterizing cooperation between primary care and mental health as an unresolved issue, Berardi et al. (2007) suggest that, “The lack of national health policies on the management of common psychiatric disorders in General Practice, along with the lack of a General Practice filter to CHMCs implies, in our experience, poorly coordinated pathways to care. In fact, these patients can be visited by either GPs or psychiatrists, regardless of the severity and prognosis of their disease” (p.81). While collaborations between the family doctor and the consulting psychiatrist have proven effective in terms of continuity of care and improved patient care, the collaborative model is not widely practiced and, in some cases, is restricted to the type of psychiatric issues that can be addressed (Berardi et al., 2007).

In spite of a seemingly endless list of issues, many of Italy’s reform challenges could be addressed through more systematic collection of data (Lora, 2009; Monzani et al., 2008; de Girolamo et al., 2007). “The lack of a national mental health information system severely hampers not only planning and monitoring, but also any analysis of the mental health system” (Lora, 2009, p. 14). High quality information is viewed as a key strategic tool for strengthening Italy’s new system. “From information to action: this is the virtuous circle that we should be implementing over the next decade, promoting high quality information and using it to improve mental health systems and clinical practice” (Lora, 2009, p.15).

15.4 PREVALENCE AND MANAGEMENT OF BEHAVIORAL HEALTH CARE IN DEVELOPING COUNTRIES

Behavioral and Mental Health in Brazil The mental health policy of Brazil is inspired by the Caracas Declaration of 1990, issued at the Regional Conference for the Restructuring of Psychiatric Care in Latin America in Caracas, Venezuela (de Almeida & Horvitz-Lennon, 2010). “The Caracas Declaration was the culmination

of a process set in motion by several developments. One of them was the recognition that traditional psychiatric hospitals failed to meet the complex needs of people with mental disorders and engaged in frequent violations of patients’ human rights” (de Almeida & Horvitz-Lennon, 2010, p. 218). Federal Law 10,216, implemented in 1991, and later revised in 2001, establishes the legislative framework for a model of mental health care in Brazil that ensures the civil rights of people with mental health problems, and “defines hospitalization as the last resource in the treatment of mental disorders” (Goncalves, Vieira, & Delgado, 2012). Mental health care is supported by, and falls under, the governance of the Brazilian Ministry of Health.

The primary source of financing for mental health in Brazil is tax based (WHO Mental Health Atlas, 2005). Under Brazil’s Unified Health System, all citizens have free access to medical care including essential medications for all mental health conditions. “The medications considered essential according to the National List of Essential Medications include: carbamazepine, clonazepam, diazepam, phenytoin, phenobarbital, valproic acid, amitriptyline, hydrochloride, clomipramine, fluoxetine, biperiden, chlorpromazine and nortriptyline, lithium, carbonate, haloperidol, and risperidone” (Kantorski, Jardim, Porto, Schek, Cortes, & Oliveira, 2011, p. 1476). The essential medications are available at the primary care level as well as pharmacy units under The Brazilian Popular Pharmacy Program instituted in 2004. High cost drugs for chronic conditions such as epilepsy, Alzheimer’s disease, and schizophrenia, are also part of an essential list of medications and financed by the Ministry of Health.

Kantorski et al., 2011, suggest that among the factors affecting the choice of an appropriate treatment, the costs of medication is a “complicating factor” in gaining access to medication. While community-based mental health centers were created to improve the accessibility of medications, many users need to buy their prescribed drugs. The costs of antipsychotics for users are 5% of the minimum salary for one day at the lowest price available, and for antidepressant medication it is 6% of the minimum salary for one day for the most inexpensive drug available (WHO-AIMS, 2007). “These are rather high values for people receiving less than one minimum salary or in some cases, no income at all” (Kantorski et al., 2011, p. 1476). Approximately 51% of the population receive low income salaries or none at all. In 2007, Brazil enacted directives that place responsibility on the states of the Federation and the municipalities to manage the procurement and distribution of psychotropic drugs (Kantorski et al., 2011).

A study of federal expenditures on mental health from 2001–2009 revealed a 53.1% increase in the funding of Brazil’s mental health program (Goncalves, et al., 2012). This growth in expenditures revealed a significant increase in expenditures for community-based services (from 8% to 15% in 2005) and a decrease in funds allocated to hospital expenses, (from 95.5% to 49.3 % in 2005) (de Almeida & Horvitz-Lennon, 2010). “From 2006 onwards, resource allocation was shifted towards

community services. The funding component played a crucial role as the inducer of the change of the mental healthcare model. The challenge for the coming years is maintaining and increasing the resources for mental health in a context of underfunding of the National Health System” (Goncalves et al., & Delgado, 2012).

Although Brazil demonstrates more fully developed mental health reform processes than other countries in the Latin American region, the outlay of federal spending for mental health is extremely small (de Almeida & Horvitz-Lennon, 2010) ranging between 2.0% and 5% of the country’s federal health budget (Goncalves et al., 2012; de Almeida & Horvitz-Lennon, 2010). Current data indicate mental health spending in Brazil estimated at 2.35% of the total health budget (Almeida & Horvitz-Lennon, 2010), an investment in mental health that falls below the expenditure of 5% recommended for the adequate development of mental health services (Kantorski et al., 2011).

According to the WHO Mental Health Atlas (WHO, 2005), Brazil’s mental health personnel include 4.8 psychiatrists, and 31.8 psychologists per 100,000 population. Alternative data collected in 2005 indicate that there are 6,003 psychiatrists, 18,763 psychologists, 1,985 social workers, 3,119 nurses, and 3,589 occupational therapists working for Brazil’s Unified Health System. At the primary care level there are 104,789 physicians, 184,437 nurses and nurse technicians, and 210, 887 health agents (Mateus et al., 2008). Regional variations in staffing are evident in Brazil’s north-south divide. As compared to the wealthy, industrialized southeast region with approximately 5 psychiatrists per 100,000 inhabitants, the poverty-stricken northeast region has less than 1 psychiatrist per 100,000 inhabitants (Mateus et al., 2008).

The shortage of psychiatric nurses is a problem in all geographic areas of Brazil. The insufficient numbers of psychiatric nurses in many countries is attributed to the stigma of mental illness, low salaries, concerns about safety, the lack of teamwork, and the fact that mental health nursing has not been a priority for decisionmakers or education systems (WHO, 2007). “Psychologists outnumber psychiatrists in all regions of the country. The distribution between urban and rural areas is also disproportionate. The density of psychiatrists in or around the largest city (Metropolitan Sao Paulo) is 1.75 times greater than the national average” (Mateus et al., 2008).

National epidemiological data on mental illness in Brazil are scarce or not available (Schmidt et al., 2011). However, several local studies and surveys indicate that the psychiatric burden of diseases is significant, about 19% (Gadelha et al., 2002).

• In 2007, 72% of all deaths were attributable to NCDs (principally, cardiovascular disease, chronic respiratory diseases, cancer, and diabetes). NCDs are the main source of the disease burden in Brazil with neuropsychiatric disorders being the largest contributor (Schmidt et al.,

2011). “Most of the burden from neuropsychiatric disorders is due to depression, psychoses, and disorders attributable to alcohol misuse” (Schmidt et al., p. 1950).

• The most prevalent disorders in Brazil include nicotine dependence, alcohol abuse, anxiety disorders, and somatoform disorders; depression is the most common mood disorder (WHO, 2005).

• Depression and anxiety disorders in Brazil are more prevalent in people who are unemployed, have low education and income (Schmidt et al., 2011). Fregni (2007) points out that while Brazil has the eighth largest economy in the world; it has one of the worst income distributions. “These statistics explain why Brazilians get depressed.” The difficult economic situation finds many Brazilian children dropping out of school early to help out their families. Researchers estimate that about 95% of children have access to school in Brazil but only 59% finish the 8th grade (Tramontina et al., 2001); low educational status is one of the known determinants of poor mental health. Belfer and Rohde (2005) observe that “street children with overt mental health problems go totally unattended” (p. 359) in Brazil.

• According to WHO, in 2003 18.8% of Brazilians were diagnosed as having depression in the last 12 months (Schmidt et al., 2011).

• A survey of 8th grade students (average mean age 14 years) in Brazilian state capitals revealed 71% had experimented with alcohol, 27% had consumed alcohol in the past 30 days, and 25% had been drunk at least once in their lives (Instituto Brasilerio de Geografia e Estatistica, 2009).

• Findings from a Brazilian study of school students aged 7 to14, in a medium sized city in the state of Sao Paulo, revealed the overall prevalence rate of psychiatric disorders as 12.7%. Disruptive behavior disorders were the most prevalent (7.0%) followed by anxiety disorders (5.2%). Lower prevalences were found for hyperkinetic disorders (1.8%) and depressive disorders (1.0%) (Fletlich-Bilyk & Goodman, 2004).

• In a systematic review of dementia among elderly Brazilians, Fagundes, Silva, Thees, & Pereira (2011) observed that dementia was most prevalent among poor, illiterate, female, and very elderly individuals. Between 1996 and 2007, age-standardized dementia increased from 1.8 per 100,000 to 7.0 per 100,000, (Schmidt et al., 2011, p. 1951).

An outstanding feature of mental health care in Brazil involves the significant and growing role of mental health in primary care. Under Brazil’s healthcare system, patients can receive treatment for their physical and mental health problems. In the context of primary care and an active commitment to mental health reform aimed at community-based care, Brazil provides mental health services

through an “interconnected Comprehensive Mental Health Network” (Lazarus & Freeman, 2009, p. 26) that consists of the following components (Mateus et al., 2008).

• Family Health Teams (FHTs) are the model of primary care for Brazil as a whole, (Lazarus & Freeman, 2009). FHTs provide service to geographically defined areas throughout Brazil including the rural areas. The core providers of mental health care in FHTs usually include a GP, at least one nurse or nurse technician, and a community health worker (Lazarus & Freeman, 2009). The Mental Health Network provides support to FHTs through Mental Health Teams (MHTs) staffed by psychiatrists, psychiatric nurses, psychologists, social workers, and occupational therapists. Mental health care under the primary care model emphasizes joint collaboration, i.e., collaborative or shared mental health care. “Rather than transferring care through up and down transfer referral, collaborative care facilitates care remaining at the primary care level but with shared responsibility for decisions. This approach ensures good quality mental health care while also building the competence and autonomy of primary care practitioners. Therapeutic groups are facilitated by mental health and primary care professionals, while community workers and lay participants, run support groups” (Lazarus & Freeman, 2009, p.26).

• Psychosocial Community Centers (CAPS) provide specialized outpatient day and limited in-patient care. CAPS treat moderate to severe mental disorders with an emphasis on the severe (Mateus et al., 2008). The mental health teams of CAPS typically include a psychiatrist, a registered nurse, and professionals in areas such as social work, occupational therapy, and nursing assistants. CAPS are organized according to three levels of care. CAPS I units are located in small towns (20,000–50,000 population) and are open 5 days a week. CAPS II units provide service to medium size cities (50,000–200,000 inhabitants). CAPS III units are large units targeted at large cities (more than 200,000 inhabitants) and are open 24 hours a day including 5-24 hour beds for admissions. There are 66 CAPS for children and adolescents, and 109 CAPS for alcohol and drug problems (de Almeida & Horvitz-Lennon, 2010). Mateus et al. (2008) observe that CAPS for alcohol and drug abuse are strategically placed in cities where the problem shows a high prevalence. However, these CAPS are unevenly distributed with lower numbers in the north and northeast regions than the south and southeast regions.

• The Return Home Program provides help to individuals with long histories of psychiatric hospitalization, to regain their footing in the community through a monthly stipend transferred to their bank accounts. In 2006, there were 2,519 people receiving this benefit in the country.

• Psychiatric Hospitals, of which Brazil has 228, are either public or private and provide services to the public system. The total number of beds in psychiatric hospitals is 50,045 (27.17 beds per 100,000 inhabitants). The average length of stay in mental hospitals is 65.29

days. There are 592 general hospitals offering some psychiatric beds in general wards (approximately 1,224 beds). Data on the number of beds available for the destitute, persons with mental retardation, or in detoxification inpatient facilities is not available (Mateus et al., 2008). Brazil has 25 hospitals for custody and psychiatric treatment of criminal patients that are suspected of having, or actually have, a mental illness. The forensic hospitals are run by the prison system.

• Residential Facilities numbered 418 in 2006. These community residential facilities are allowed a maximum of 8 residents (Mateus et al., 2008).

Over the past two decades, Brazil has demonstrated remarkable progress in an attempt to restructure its mental health system to reflect the community oriented aims of the Caracas Declaration. Several innovative programs, such as CAPS and the Return Home program, have replaced flagging outpatient services through a “mixed system of mental health outpatient services, day hospitals, and therapy workshops” (Mateus et al., 2008; Jacob et al., 2007). Additionally, Sobral, a city in Brazil’s low-income northeast region, is frequently referred to as a successful example of fully integrated mental health care in primary health care (Lazarus & Freeman, 2009; WHO/WONCA, 2008). The Sobral model “demonstrates the value of a number of interlocking strategies: a strong system of family centered primary health care (particularly appropriate for mental health care) together with specialist mental health support delivered through collaborative care and a network of supporting mental health resources including both hospital and community” (Lazarus & Freeman, 2009, p. 27).

Despite Brazil’s impressive gains in mental health reform, and in less than two decades, the country faces a number of challenges. Several factors create huge treatment gaps in the delivery of mental health care, i.e., the proportion of people who need care and do not receive it (Rodriguez, 2010, p. 339). The difficulties start with the uneven distribution of mental health services at nearly every level of care. Typically, inhabitants in the urban areas have greater access to mental health services than those living in rural areas. The greatest number of health professionals, psychiatric beds, and CAPS are located in the urban areas. The north and northeast have fewer CAPS than the south and southeast regions (Mateus et al., 2008). Fregni (2007) introduces a phenomenon known as the “inverse care law” to characterize the socioeconomic factors that negatively impact access to mental health care: “At the present time, lower income populations that suffer the most from depression receive less mental health care, compared to the more privileged population.”

Primary care is a part of Brazil’s mental health system but it is limited and not well integrated. As Lazarus and Freeman (2009) explain, “The approach was developed during a period of general health care reform in Brazil (and Sobral in particular) that provided a set of favorable circumstances that may not be present in other contexts. The failure of some municipalities to authorize

prescribing rights for primary care practitioners suggests, however, that there has not been universal acceptance of the value of primary mental health care–whether by primary care practitioners themselves, or mental health specialists” (p.41). Primary care is in need of more health professionals, and there is a need to expand training of GPs and general health professionals in the area of mental health.

The efficiency of the system would be enhanced if Brazil’s academic institutions helped with the development of key common mental disorders guidelines to be applied in primary health care (Mateus et al., 2008). The mental healthcare system requires more psychiatric nurses, more beds in general hospitals, and more CAPS dedicated to address the mental health needs of children and adolescents.

Researchers consistently point to Brazil’s “chronic” lack of clinical research in mental health. “Research conducted in Brazil does not necessarily address national health priorities because research grants are based only on scientific merits. Researchers usually choose topics likely to be published internationally such as clinical trials involving newer and more expensive drugs. Information generated from this research does not benefit the poor” (Fregni, 2007). Mateus et al. (2008) add that there is a need to develop standardized epidemiological tools to aid in the systematic collection of data concerning the prevalence and incidence of mental disorders.

In the global market of escalating drug prices, sometimes 30 times higher than traditional psychotropic medication, Brazil must identify alternatives that are tailored to its socioeconomic conditions. For example, there are studies which demonstrate that “old antidepressants can be as effective as newer antidepressants; therefore these old drugs need to be included and mandatory in the psychiatric training. This is especially important as physicians are more likely to prescribe and use drugs with which they have experience” (Fregni, 2007).

Similar to many countries, Brazil is facing the challenge of meeting the mental and physical needs of a rapidly aging population; this issue involves an inevitable burden on families. “Moreover, changes such as smaller families and more women in the paid workforce have reduced families’ ability to provide support and health care for elderly people” (Schmidt et al., 2011, p. 1955). Finally, increasing the health budget to 5% will provide Brazil with a sounder financial basis for strengthening the mental health system and narrowing treatment gaps. Careful attention must be given to directing funds to community-based and ambulatory services rather than psychiatric hospitals.

Brazil is committed to creating a viable mental health system. In October 2009, nearly 20 years after the Caracas Declaration, the 49th Directing Council of the Pan American Health Organization (PAHO/WHO) approved the Strategy and Plan of Action on Mental Health for the Region of

Americas. Brazil’s Ministry of Health has adopted this plan. The Regional Strategy emphasizes the development of national mental health policies and laws, the psychosocial development of children, primary healthcare centered mental health services delivery, and capacity building in terms of human resources and strengthening the capacity to produce, assess, and use information on mental health (Rodriguez, 2010, p. 339).

Behavioral and Mental Health in Cuba Cuba, considered a developing country by the World Bank standards, in regard to its healthcare system is more characteristic of a high income country. Cuba commits 50% of its total health budget to mental health. Similar to its general healthcare policies and provisions, mental health services are structured and provided at the primary care level, with direct care and services provided by primary healthcare physicians, psychiatrists, and psychiatric nurses based in the community. All primary care mental health professionals receive regular training. The Cuban structure of mental healthcare supports 1 medical doctor for every 200 persons, making the integration of mental health care and services almost seamless (WHO, 2005).

Although the emphasis is on community-based care and services, where 75% of mental health services are provided, there are 7.36 psychiatric beds per 10,000 in the population which equates to each of the 14 regions in Cuba having a 20–30 bed psychiatric unit. There are 10 psychiatrists per 100,000 in the population, 7.7 psychiatric nurses, and 1.9 psychologists (WHO, 2005).

The community-based mental healthcare stresses prevention, promotion, and intervention, especially in the home and residential facilities with family integrally involved. Comprehensive mental health services are provided as well as social rehabilitation that includes vocational and employment training and education (WHO, 2005).

Cuba has had a substance abuse policy since 2000 that has been 50%–75% implemented and a National Mental Health Program that was 85–90% implemented by regional and national authorities by 2000. Other legislation policies and initiatives include a substance abuse policy initially developed in 2000 that decentralizes mental health resources. Special populations include older adults and children, and there are special programs for victims of domestic violence, suicide, substance use, and social rehabilitation. The ICD-10 system is used for data collection purposes (WHO, 2005).

Using a representation sample of 1,140 persons over the age of 60 from two Cuban regions and using a two stage sampling technique, DSM-III-R and NINCDS-ADRDA criteria, Libre et al. (1999) reported the following findings:

• Dementia was found in 8.2% of the population, of which 5.1% was attributed to Alzheimer’s Disease and vascular type dementia.

• Dementia was positively correlated with being female and without a spouse.

• Of the sample, 45.2% reportedly were drinkers, although the overall prevalence of alcohol dependence in the over 15 year old population is 8.8%.

• The eastern regions had higher prevalence rates of alcohol drinking.

• Smoking was highly correlated with heavy drinking.

• Suicide was higher in rural areas of Cuba among older adult men, although women had more suicide attempts than men.

Reynaldo et al. (2002) used a psychometric testing and structured interventions to assess the prevalence of psychiatric disorders in 150 patients with spinocerebellar ataxia type 2, and found that 88% manifested symptoms related to mental disease which included disorders involving adaptation, sleep, mood, and sexual disorders. Mental retardation and dementia were also diagnosed.

Cuba has a relatively high mental illness prevalence rate with an associated high incidence of violent acts. In fact, homicide, suicide, and violent events, considered external causes of death, account for the fourth leading cause of death in Cuba. Cuba’s suicide rate is inordinately higher than other Caribbean countries of similar background and region (deGordon, nd). Annual suicide deaths per 100,000 in Cuba for 2003 – 2005 was 13.6, while the rate in the USA was 10.8 (PAHO, 2009). Many attribute the external causes of death in Cuba to the high rates of alcohol consumption or binge drinking, reported as 80% of the adult population (deGordon, nd).

Other areas of mental health concern in Cuba include the high abortion rate—although declined from 1999, it is still among the highest in Latin America (Sixto, 2002)—and a homicide rate of 7.0 per 100,000. Also, there seems to be a steady increase in posttraumatic stress disorders, dementia, and cognitive impairment. In 2000, The Pan American Health Organization (PAHO) reported that 4.38% of Cuba’s population between ages 60 and 74 suffered from Alzheimer’s dementia. This prevalence jumped to 22.6% for Cubans 75 years and older (PAHO, 2002).

Typically, the majority of Latin American countries devote less than 2% of their total health budget to mental health, perpetuating the problem of burden of diseases. Such problems as stress-related relationship violence and sociopolitical stressors go unaddressed. Latin America shows 10.5% of the world’s total burden of disease due to neuropsychiatric disorders, among which unipolar

depression represents 35.7% of the psychiatric problems, alcoholism represents 18.2%, schizophrenia 7.8%, bipolar affective disorder 6.6%, and substance abuse 5.6%.

Behavioral and Mental Health in India Psychiatric epidemiology studies lag behind other branches of epidemiology. According to Math, Chandrashekar, and Bhugra (2007) epidemiological studies report “prevalence rates for psychiatric disorders in India from 9.5 to 370/1,000 in the population” (p. 183). These discrepancies can be attributed to, “difficulties encountered in conceptualizing, diagnosing, defining a case, sampling in selecting an instrument, lack of resources and stigma” (Kessler, 2000). These discrepancies, commonly seen in international studies, although not specific to India, could impact planning, funding, and healthcare delivery. Providing accurate data about the prevalence of mental disorders in the community would help to justify the allocation of scarce resources and planning of health services (Math et al., 2007).

Math et al. (2007) attempted to critically evaluate the overall prevalence rate of psychiatric disorders as reported in epidemiology studies from India. With the exception of one study, all the past epidemiological studies have surveyed a population of less than 6,000 raising questions about generalizing the findings to even one country like India. However, the findings of one study suggest that, “mental healthcare priorities need to be shifted from psychotic disorders to common mental disorders like depression, anxiety disorders, somatoform disorders, etc. which are also associated with high disability in all measures” (Patel et al., 1998).

Chandra et al. (2001) report that India has an estimated 5.8% prevalence rate of mental illness with the highest prevalence in females over 55 years old. Depression is reportedly the most common problem among individuals 60 years and older. The national suicide rate is 9.2 per 100,000 in the population (males 10.6 and females 7.9). Suicide is highest among the 30- to 44-year-old age group. The most common method of suicide is by poisoning and hanging. Epilepsy and hysteria are significantly higher in rural India than in the urban areas (Chandra et al., 2001).

In a study assessing the prevalence of suicide, clinical depression, and anxiety disorders in a sample of 150 men who have sex with men (MSM) in Mumbai, India, Sivasubramanian et al. (2011) found that “the frequency of psychosocial and mental health problems among MSM in Mumbai was strikingly high suggesting a significant mental health burden exists among this population” (p. 458). Further, 45% reported current suicidal ideations, suggesting that there is a significant unmet need for mental health services for MSM in Mumbai (p. 458).

India has the greatest number of HIV infections of any nation in Asia and the third largest national HIV epidemic in the world (UNAIDS, 2008; UNAIDS & WHO, 2008). While the generalized

heterosexual epidemic of HIV in India appears to be stabilized or declining (Arora, Kumar, Bhattacharya, Nagelkerke, & Jha, 2008) “MSM …prevalence estimated to be 7.4% nationally, is 12.5% in Mumbai, India’s largest city” (Kumta et al., 2010; National AIDS Control Organization, 2008). The role of mental health, although unclear, may be linked to the associated stress experienced by MSM.

India spends 2.05% of its total health budget on mental health. The primary funding sources financing mental health, in descending order, are taxes, out-of-pocket, private insurance, and social insurance (WHO, 2005). India has re-strategized its approach to mental health. It aims to provide a balanced mix of closely networked services with budgetary support for modernizing government-operated mental hospitals, strengthening its medical colleges, and departments of psychiatry, and implementing a 100 district mental health program. During the first phase of this program the focus will be on improving information, education, communication strategies, training, and research. This first district-wide mental program covers 24 districts; however the plans are to expand the program to 100 districts by 2020 (Chandra et al., 2001).

Mental health care in India is part of the primary healthcare system and is available in 22 of 660 districts in India. The plans are to eventually expand to 100 districts. India’s Mental Health Act of 1987 simplified admissions and discharge procedures and provided facilities for children and drug abusers. This legislation also promoted human rights for the mentally ill. Other mental health legislative initiatives that seek to protect the rights of the mentally ill include the Juvenile Justice Act, The Persons with Disabilities Act, and the Narcotic Drugs and Psychotropic Substance Act last amended in 2001 (WHO, 2005). Services provided by the government health center are free. The country also has limited disability benefits for persons with mental illnesses.

There are 0.25 total psychiatric hospital beds in India per 10,000 in the population (0.2 in mental hospitals and 0.05 in general hospitals). One-third of the mental health beds are confined to one state (Maharashtra). Several states have no mental health hospitals at all. For the hospitals with beds, many of the beds are taken up by patients who have long term stays. During the past two decades, many mental hospitals have been reformed through the interventions of volunteer organizations such as Action Aid India and the National Human Rights Commission. However, mental hospitals still have shortages of drugs and other treatment. Also, there are very few mental health beds in rural areas, resulting in family being encouraged to stay with patients who were voluntarily admitted. Some beds are specifically designated for the care of patients who were admitted for drug treatment and some are designated for children.

There are 0.2 psychiatrists per 100,000 in the population, 0.05 psychiatric nurses, 0.03 psychologists and social workers. Keeping mental health professionals is a challenge for India. For

example, in 2003 India lost more than 82 psychiatrists to the United Kingdom where they went for training sessions and never returned (WHO, 2005). Similar to other countries, NGOs are involved in mental health in a variety of ways. They assist with counseling, suicide prevention, training of lay counselors, and providing rehabilitation through day care, sheltered workshops, halfway houses, and providing hostels for recovering patients, and long-term care facilities as needed. They also support, advocate for, and operate family self-help programs. There is, however, no consistent data on evaluation of care outcomes or epidemiological studies on mental health for disaster affected populations and older adults, and there are no documented school-based programs (WHO, 2005).

Jorm (2000) suggests that mental disorders in India are, “highly stigmatized conditions that many people want to keep private because of their embarrassment or fear of discrimination” (p.187). According to Math et al. (2007), the problem with systematic underreporting continues to be a major challenge for the future of psychiatric epidemiology in India (p. 187).

Behavioral and Mental Health in the Russian Federation Soviet psychiatry is the predecessor of modern day psychiatry in the Russian Federation (Polubinskaya, 2008). For several decades, including the Soviet era, mental illness was regarded as a biological disease. Soviet psychiatry operated from this disease perspective. In this context, mental illness was viewed as a sickness (Jenkins, et al., 2007) that required medical treatment, and in severe cases, institutionalization. The disease focus was not person-centered, psychodynamic, or introspective, and except for a few rehabilitative measures, such as work therapy, treatment of the mentally ill was largely somatic in nature (Roth, 1994). Polubinskaya, (2008) suggests that the predominantly biological nature of psychiatry in the Soviet era meant that the patient’s psychology, problems, and rights, did not take first place with the psychiatrist.

The disease focus, along with other factors of Soviet society, set the stage for the abuse of psychiatry and “total neglect for the human rights” of the mentally ill (Polubinskaya, 2008). The Soviet abuse of psychiatry was associated with the practice of hospitalizing people who were not mentally ill for their dissident political or religious beliefs (Lavretsky, 1998, p. 537). “The lack of a democratic tradition in Russia, a totalitarian regime, and oppression and extermination of the best psychiatrists during the 1930-50 period, prepared the ground for the abuse of psychiatry and the Russian-Soviet concept of schizophrenia” (Lavretsky, 1998, p. 537). A complex array of causes has been attributed to the abuse of psychiatry in Soviet Russia, starting with the imprecision of the disease model and diagnostic criteria, particularly the classification of schizophrenia. “The interpretation of any deviation from the norm by a psychiatrist as a symptom of schizophrenia played an important role in the abuse of psychiatry in the Soviet Union (Polubinskaya, 2008). The

problem of inadequate diagnostic criteria was fueled by Soviet psychiatry’s isolation from different schools of thought regarding the etiology and treatment of mental illness, poor standards of clinical training and practice, and the absence of a legal infrastructure and a professional code of ethics.

Since the fall of the Soviet Union, the new Russia has attempted to address a Soviet legacy of difficult psychiatric practices including the political abuse of psychiatry. The Ministry of Health and Social Development provides the central policy for the delivery of mental health care in Russia. In keeping with the democratic aims of Glasnost (openness) the Russian Federation Mental Health Act was adopted (On Psychiatric Care and Guarantees of Citizens’ Rights) in 1992. The Law of Psychiatric Care called for professional accountability through the creation of a code of ethics, a respect for patients’ rights, and monitoring of psychiatric facilities to ensure the observance of patients’ rights. The law established what was missing in Soviet psychiatry—a legal foundation for the delivery of psychiatric care. The law “became the first step in the reform of Russian psychiatry” (Polubinskaya, 2008). From a therapeutic perspective, the law was aimed at encouraging the development of the psychiatrist–patient relationship as a partnership rather than the dominant paternalistic relationship of Soviet psychiatry (Gurovich, 2007, Bartenev, 2004).

The Medico-Social Expert Commission (MSEC), established under the Ministry of Health and Social Development, plays a pivotal role in the Russian mental health system (Jenkins, et al., 2010) and “acts as a gatekeeper to social protection services, including pensions, rehabilitation, and employment services” (p. 222). Local branches of the MSEC assess the level of disability of individuals with physical or mental problems. The evaluations of MSEC staff can affect whether or not people are able to access rehabilitation and employment services. Jenkins, et al. (2010) identify a critical issue of access presented by MSECs: “In Russia, the emphasis remains on medical aspects of treatment, without adequate consideration of social and occupational rehabilitation. Links with local employment services are weak. To promote social inclusion, steps must be taken to encourage and facilitate cooperation and collaboration between the MSECs, employment services and medical services” (Jenkins, et al., 2010, p.222).

Russia’s mental health services are financed through central taxation followed by the ministries of each oblast determining how funds will be allocated. The essential levels of care provide free medication to people who are hospitalized, disabled due to mental illness, and those affected by schizophrenia and epilepsy; medications for outpatients services are inexpensive (WHO 2005, p. 392). “The compulsory insurance scheme introduced in the 1990s and funded through central taxation does not include coverage for outpatient mental health counseling. Russian employers typically do not have private insurance that allows for third-party payments to cover mental health counseling or psychotherapy. This means counseling is available only to those who can afford

private fees, or have access to an Employee Assistance Program (EAP)” (Sharar & Shtoulman, 2010).

Mental health spending is a low priority in most health systems across cultures. “Two-thirds of the world’s population live in countries that spend less than 1% of their total budget on mental health services including 15 out of 19 countries in Africa for which data were reported” (Dixon, McDaid, Knapp and Curran, 2006, p.171). Russia is on record for having spent 0.2% of the GDP in the mid 1990s on mental health initiatives which eventually failed due to lack of funding (Jenkins et al., 2007; Polubinskaya, 2008). Data on the specific amount of the GDP budgeted for mental health spending in Russia is not available (WHO, 2005). “Despite the staggering social and economic impact there is little interest or priority given by public and private funders to the development of mental health services in Russia” (Fuchs, 2007, CCDS, 2007).

Russia’s mental health infrastructure consists of the following services (Gurovich, 2007):

• Inpatient hospital care or psychiatric hospitals which provide specialized psychiatric care (e.g. suicidological, neuropsychiatric, sexological, adolescent, gerontological).

• Dispensary services or Psychoneurological Dispensaries (PNDs) are mental health institutions which focus on outpatient care and provide rehabilitation services, specialized psychiatric services, occupational therapy facilities, and hostels for individuals who have lost their social connection.

• Out-of-Dispensary Services also provide outpatient care, and emphasize service delivery in consulting rooms which are located within inpatient and outpatient facilities, institutions, and industrial work settings. Consulting rooms are a predominant form of mental health delivery in rural areas.

• Community Crisis Response Services, created in the 1990s under the Ministry of Emergency Situations, provide medical and psychological services related to wars, ecological disasters, homelessness, violence, emergencies, post-traumatic stress, psychosomatic disorders and forced migration (refugees).

There are reportedly up to 450,000 active NGOs in Russia (Flounders, 2006); however the number of NGOs providing service to the mentally ill is insufficient (Krasnov, Gurovich and Bobrov, 2010). According to WHO 2005, only 10 NGOs provided mental health services including social service support by religious organizations such as the Russian Orthodox Church (WHO, 2005). Treatment centers for drug and alcohol addiction operate outside of the mental health system. People who use the cost-free state services are put on the government’s drug user registry. However, many prefer to pay for treatment and avoid the consequences of registration. “The drug

user registration system keeps users away from substance abuse clinics by penalizing rather than rewarding treatment-seeking behavior” (Human Rights Watch, 2007, p. 56). In spite of confidentiality laws, drug users are concerned that registration will affect their ability to keep a job or seek employment opportunities, and restrict their ability to drive or own a car The continuous underfunding of treatment clinics, long wait lists, and the threat of the registry have led to the widespread practice of out-of-pocket payments. Patients who can afford to pay have access to higher quality service (Bobrova et al., 2007; Human Rights Watch, 2007). A qualitative study of Intrauterine Device (IUD) users in Russia identified three main barriers to treatment access: financial constraints, the fear of stigma, and the perceived low effectiveness of treatment procedures (Bobrova, Alcorn, Rhodes, Rughnikov, Neifeld, & Power, 2007).

In 2003, the number of mental health professionals included 14,439 psychiatrists, and 1,939 psychotherapists per 10,000 of the population. Recent data indicates that psychiatrists outnumber mental health specialists (e.g., psychologists, social workers) by a ratio of 4 to 1, and there are regional differences in the number of specialists throughout the country (Gurovich, 2007). According to Jenkins et al. (2010) “The shortage of social workers in Russia, which is exacerbated by the fact that many new social work graduates seek employment in the higher paid private sector, means that social work is severely constrained” (p.223). Gurovich (2007) emphasizes that low salaries are only part of the difficulty of attracting specialists to psychiatry and that “the initiative of mental health system administrators is insufficient” (p. 2).

Despite a significant decrease in psychiatric beds since 1990 (40,000 beds or one-fifth of its total bed capacity) (Gurovich, 2007), Russia has the highest number of psychiatric beds in the European Union with a reported 164,752 beds or 11.6 per 10,000 of the population in 2003 (Bartenev, 2004). Gurovich (2007) points out several issues related to Russia’s bed capacity that raise questions for the development of community-based care: the high length of stay for all patients in general (77.4 days in 2006); the high rate of rehospitalizations in hospitals more than one year; and the hospitalization of patients with non-psychotic disorders who could be receiving outpatient services. “In Russia, bed capacities are also highly centralized: more than 40% of beds belong to large hospitals of at least 1000 beds each. The question arises: With respect to reducing bed capacities, are we really achieving the goal of departing from relying on the hospital component of our mental health services?” (Gurovich, 2007).

Russia’s mental health problems are as concerning as the health issues it is struggling to address. Dwindling social support services, unemployment, and an unstable economy following the collapse of the Soviet Union, are often cited as critical factors that account for Russia’s poor mental health outcomes. However, certain culturally condoned norms (Oxford Analytica, 2009) as well as unhealthy life styles (e.g., poor nutrition) figure significantly in Russia’s mental health challenges.

For example, Russia’s problems with alcohol and tobacco consumption are legendary. One million people die each year from alcohol and tobacco related illnesses in Russia (NBGH, 2011). As a country in the depths of a population crisis, what Russia regards as lamentable is that alcohol and tobacco consumption are among the leading causes of preventable deaths. With regard to the prevalence of smoking in Russia, approximately 60% of all adult men over age 18 smoke; more than half of teenagers smoke (approximately 60% males, and 40% females); and approximately 27.5% of 15-year-old males and 18.5% of 15-year-old females are current smokers of at least 6 cigarettes per day at least 17 days per month (NBGH, 2011).

The prevalence of alcohol consumption in Russia has been captured in banner headlines: “The Kremlin estimates that Russians consume 32 pints of pure alcohol per capita per year, more than double the World Health Organization’s recommended maximum” (Osborn, 2011). The estimated percentage of disability-adjusted life years lost (DALYs) due to alcohol is 28% for men and 11 percent for women, much higher than in other large countries such as the United States, Brazil, Germany, or China. (Oxford Analytica, 2009). Heavy drinking in Russia has exacted tremendous social costs in terms of reduced workplace productivity, high rates of absenteeism from work (as high as 75%), traffic accidents, violence, elevated crime levels, and the breakdown of family life (RIA Novosti, 2011; Sharar & Shtoulman, 2010; Oxford Analytica, 2009). According to the United Nations, Russia had the world’s highest rate of divorce in 2010 (RIA Novosti, 2011). Russian government officials indicate that 75% of the 12,000 murders prosecuted in the country in 2010, were carried out under the influence of alcohol (Osborn, 2011).

The status of mental health in Russia is characterized by more dramatic statistics. News stories worldwide report that in the 20 years since the break-up of the Soviet Union, 800,000 people committed suicide, “more than one every 15 minutes in a country with a population of 142.9 million” (Amos, 2011). In 2002, Russia had the second highest rate of suicide for men in the world (McDaid et al., 2006) particularly in the middle-aged group. “The WHO Global Burden of Disease Study reported that in 2002, Russian men had the highest rate of suicide in the WHO European region with rates of 69.3 per 100,000 males and 97.2 per 100,000 in the 45-54 year old age group” (Fuchs, 2007). Current WHO data place Russia as having the sixth highest suicide rate in the world, with 23.5 per 100,000 people, while the country’s Sebersky State Research Center indicates that Russia has the second highest suicide rate in the world, with Lithuania in the lead (Chaykovskaya, 2011). Suicide rates for Russian children are equally as gripping. Russia has the third highest rate of adolescent suicide in the world behind Kazakhstan and Belarus, (UNICEF, 2011). Approximately 1,500 teenagers between the ages of 15 and 19 commit suicide each year (UNICEF, 2011); similar to other countries, the suicide rate for this age group is higher for adolescent males--on average, 10.5% (Wasserman et al., 2005). “Poverty is not the leading cause of suicide. According to various research data, up to 92 per cent of suicides among children and

adolescents are directly or indirectly rooted in their disadvantaged family situation (parental alcoholism, conflicts in the family, abusive treatment)” (UNICEF, 2011).

Approximately 10% of the Russian population, or at least 3 million Russians, (Levina & Lubov, 2007) suffer from a severe mental illness. Krasnov et al. (2010) report the prevalence of mental disorders registered in psychiatric institutions as 2,978.7 per 100,000 population. From the perspective of family burden, “More than 80% of these people are cared for by their family members. In total, considering the number of family caregivers, mental illness directly affects at least 10 million Russians, or one in every fifteen people. However, the mental health service system has an extreme deficit of personnel skilled in psychosocial support and intervention, resulting in little support for families” (Levina & Lubov, 2007). In 2002, 934,200 people were certified with disabilities because of mental illness (Bartenev, 2004). Sharar and Shtoulman (2010) indicate that this number has reached 1 million. “Mental health problems such as depression and bipolar illness account for 20% of all those registered as disabled” (p.3).

Similar to the country’s healthcare system, primary care in Russia’s mental health system is underdeveloped and offers little to people with psychological problems (Sorlie, Rezvy, Hoifodt, Yashkovich, & Proselkova, 2011). Krasnov et al. (2010) speak to the urgent need to develop and reform outpatient psychiatric services due to the increasing numbers of primary care patients (25–30%) that require a psychiatric consultation. In their look at the issue of primary care in post-communist countries, Jenkins, Klein, and Parker (2005) point out issues in contemporary Russia’s mental health services that are reminiscent of issues in Soviet Russia: “Primary care services are not generally expected to manage common mental disorders, and most simply refer patients to specialist services. While access to essential medicines is usually possible, access to evidence based psychological interventions is still limited. This arises from isolation from the West, and poor awareness of the international evidence base on diagnosis, effective services, and interventions.” (p. 173).

The new Russia has attempted to shed the narrow model of Soviet psychiatry in favor of mental health initiatives that emphasize community-based care. Under Russian mental health law, GPs with no specific specialization in psychiatry have been barred from diagnosing or treating mental health disorders. Recognizing the important role of mental health services in primary care, recent amendments in 2011 will “enable General Practitioners to treat depressive and psychosomatic disorders, diagnose serious mental disorders and follow up psychiatric patients after their treatment by the specialist health services” (Sorlie, et al., 2011, p. 1568). Over the past decade, interventions such as The Sverdlovsk Mental Health Reform Project, an action research project aimed at establishing an integrated approach to mental health reform (see Jenkins, et al., 2007) and the Canada-Russia Disability Program, an initiative aimed at improving social work practice in mental

health settings (see Fuchs, 2007), provided Russia’s health professionals with education and training on mental health issues, evidence-based technologies, curriculum development, and psychiatric consultation. The projects demonstrate the important role of knowledge development in creating community-based care (Fuchs, 2007) and that it is possible for Russia to forge sustainable links between mental health services and primary care (Jenkins, et al., 2007).

In spite of promising moves forward, changing the balance of mental health services in the Russian Federation will require attention to a number of challenges. “Addressing these barriers is necessary to shift away from hospital-centered mental health services emphasizing institutionalization, towards multisectoral approaches that foster community-based services supported by multidisciplinary teams that foster social inclusion of persons with mental health” (Fuchs, 2007).

An outstanding issue that limits access to mental health care and impacts all levels of service to the mentally ill involves funding. In particular, hospital dominated funding must change; economic incentives must be created to overcome undue delays in discharging individuals from inpatient care, and to discourage health professionals from opposing change (McDaid et al., 2006). “Downsizing the hospital sector and shifting to community based care requires reducing or redeploying staff. This is politically difficult to achieve and requires carefully designed human resource policies” (Fuchs, 2007).

Secondly, financing regulations prevent pooling of budgets from different service sectors, and shifting funds from health to social protection services (Fuchs, 2007). The restrictive funding mechanisms hamper timely, coordinated access to mental health care. Considerable attention must be given to building the capacity of social protection services and providing patients access to housing, social services, vocational rehabilitation, and jobs (McDaid et al., 2006). Federal law in Russia requires employers to ensure that 3% of their workforce includes persons with disabilities or they will be fined. However, individuals with mental problems are rarely placed. Jenkins et al. (2010) observes that while there was a remarkable increase in hiring the disabled in the Sverdlovsk Oblast (273 individuals in 1997 to 1,540 disabled in 2002) very few jobs went to people with mental health problems. “Not surprisingly, many employers would have opted to pay the meager fine of 2,000 rubles ($70) that the law prescribes rather than employ people with disabilities. In 2003, the Sverdlovsk Oblast government collected fines amounting to two million rubles ($70,000). This revenue has been allocated to rehabilitation and sheltered work placements for people with physical disabilities but not to services for people with mental illness” (Jenkins et al., 2010, p. 224).

Finally, achieving fully integrated mental health services in the Russian Federation will require policies that address the Russian health system as a whole including financial, structural, and legal

issues (Fuchs, 2007). Commitment to mental health reform is evidenced in Russia’s federal program for The Prevention of and Fighting Against Socially Significant Diseases 2007–2011. Under this program, improving mental health services in Russia will include more emphasis on building the multi-professional team approach to mental health care; increased collaboration between mental health and social services; more attention to providing comprehensive treatment that emphasizes psychosocial interventions at early stages of patient care; and strengthening the capacity of the primary care sector, particularly in identifying non-psychotic disorders (e.g., depression, psychosomatic disorders) for people who access primary care professionals (Gurovich, 2007).

Behavioral and Mental Health in Ghana The lack of recent literature documenting healthcare initiatives, especially mental health, suggests that there have been very few changes in the healthcare system in Ghana for decades. Also, Ghana’s epidemiological data are dated.

The WHO (2008, p. 9) estimates that, “of the 216 million people living in Ghana, 650,000 are suffering from a severe mental disorder and a further 2,166,000 are suffering from a moderate to mild mental disorder. The treatment gap is 98 percent of the total population expected to have a mental disorder.” One of the reasons attributed to making it difficult for mental health practice in Ghana, is the traditional stigma attached to mental health. The traditional healing of mentally ill patients in Ghana gives rise to disturbing trends. For example, according to the WHO (2006, p.10), “in Ghana, the proliferation of spiritual churches, prayer camps and other unorthodox institutions have become threats to patient’s rights and appropriate treatment.”

In a 2006 Public Agenda report, Acting Medical Dr. Anna Dzadey of Pantang Psychiatric Hospital was quoted as saying that “more often, mental health patients are kept in police custody for a prolonged period of time without any legal reason, before being brought to the hospital for evaluation and treatment” (Public Agenda, 7 April 2006, p. 10). According to the Accra Office of the Commonwealth Human Rights Initiative (CHRI) human rights violations in prayer camps are widespread in Ghana, in the form of chaining, beating, insults, denial of food and lock-ups in crowded rooms”. The report continues, Minister of Health Quashigah says that, “his outfit was preparing various health bills that included a bill on traditional, psychic and faith based healers. It is expected that the bill will become a law which would allow the country to regulate and monitor such practices” (Public Agenda, 15 August 2008, p. 10).

Affinnih (1999) found in a sample of 117 Ghanaians that heroin and cocaine were the most common drugs abused in Ghana. Prevalence of psychiatric disorders in 96 patients revealed that 50% of them suffered from affective, neurotic, and stress disorders. Behavioral disorders and drug

use was common among adolescents. Depression, dementia, and paranoid disorders ranked highest in the over 60-year-old age group.

Although the first mental health asylum opened in Accra in 1906, Ghana did not formalize its mental health policy until many decades later. This is especially noteworthy because the asylum had housed more than 1,700 patients by 1960. Ghana enacted mental health legislation in 1961. However, it did not have a specific Mental Health Policy in place until 1994 to implement legislative mandates. The policy was later revised in 2000. The policy has the components of advocacy, promotion, prevention, treatment, and rehabilitation. The NRC Decree enacted in 1972 remains the current mental health law. There are also three legislative initiatives in Ghana that govern substance abuse. These are The Narcotic Drugs (Control, Enforcement and Sanctions) Law of 1990, PNDC Law 236, and the Pharmacy and Drug Act of 1961 (WHO, 2005).

The Ministry of Health is the core structure under which mental health services are provided. Ghana commits 0.5% of its total health budget to mental health that is supported by a tax-based source of financing. The WHO also contributes to Ghana’s mental health budget. Mental health hospital admissions, medications, and tests are subsidized unless the patient is very poor, in which case care is free. Disability benefits are available to persons with mental disorders although they are primarily available to persons who are employed in the public sector (WHO, 2005).

Mental health in Ghana is part of the primary healthcare system. Trained psychiatrists and nurses are available in most regions to respond to the needs of patients. With Danish support, regular training of especially community psychiatric nurses and medical assistants is conducted in the northern regions of Ghana. WHO support provides much-needed training of volunteers and mental health professionals staffing facilities based in the community. Ghanaians utilize “healing churches” that help with community care. Although not in abundance, there are also half-way houses and charitable institutions that support community care for the mentally ill.

There are 1.03 psychiatric beds per 10,000 in the population of which one in 10,000 beds is specifically in what is designated as a mental hospital. In Ghana’s three regional hospitals, there are approximately 10–20 beds designated as psychiatric, to which patients with mental illnesses may be admitted. There are no beds specifically designated as psychiatric in Ghana’s Military or Police Hospitals.. Rather, if necessary these patients are transferred to the already overcrowded Accra Psychiatric Hospital. This hospital also lacks the necessary infrastructure to support the number of patients or sustain the facility. There is 0.08 psychiatrists per 100,000 in the population, 2.0 psychiatric nurses, and 0.04 psychologists. Similar to India, when professionals are sent abroad for training, some do not return, presenting a particular challenge as Ghana attempts to retain qualified mental health professionals ( Who.int/country_profiles , 2005).

SUMMARY As this chapter on behavioral health suggests, providing true access to mental health care involves a number of challenges. Mental illness does not occur in a vacuum; emotional difficulties are often linked to employment issues, health problems, and family dynamics. Research on the psychological trauma experienced by those trying to adjust to a new way of life in post-communist countries, highlights the political, economic, and societal factors that can affect an individual’s sense of well-being. Studies which focus on the psychological impact of natural disasters, such as the Tsunami in Japan, the Chernobyl nuclear disaster in Russia, or the stress of living in a war torn environment, provide added perspective on the enormity of problems a country may face in its attempts to help people regain mental stability.

Over the past three decades, and with Italy leading the way as the break-through model for deinstitutionalization and community-based care, mental health care has undergone significant change in the 11 countries studied in this text. The paradigm shift emphasizes a respect for the civil rights of the patient, more humane treatment of the mentally ill by healthcare providers, and social inclusion rather than social isolation. Approaches to treatment have moved from hospitalization as the sole response in dealing with a patient’s needs to a variety of interventions such as milieu therapy, group therapy, and rehabilitation day treatment centers. Mental illness is viewed less as some type of demonic affliction that must be hidden or exorcised, and has become more broadly conceptualized along a continuum of mild stress disorders to severe psychiatric disease.

Increasingly, the mind–body connection to wellness is taking hold, i.e., good health refers to being sound physically, mentally, and socially. Countries such as Russia and Brazil are painfully aware of the interrelatedness of physical and mental health as they strive to create healthcare initiatives to address the phenomenal loss of their male population (adolescent and middle-aged) to violence, binge drinking, drunk driving, and preventable, non-communicable diseases. Deinstitutionalization has led to a dramatic decline in the use of psychiatric beds, and at the same time, called considerable attention to the important and much needed role of primary care in mental health.

The 11 countries under study share common challenges in their efforts to provide quality mental health care. The most obvious concern, particularly among the developing countries, is the low rate of mental health spending. In addition to inadequate financing, there are regional variations in gaining access to mental health services. Despite federal guidelines, states and municipalities provide mental health services based on their interpretation of need and economic capabilities. In terms of disparities, low socioeconomic groups are most likely to experience mental health distress than those with higher incomes, and urban dwellers have greater access to mental health services than those who live in rural areas. Even in situations where primary care is available, there are

issues concerning the ability of healthcare professionals to help people with their mental health concerns. Mental health patients require a number of services. Providing well-coordinated, continuity of care is an ongoing challenge. Researchers suggest that service effectiveness and efficiency could be improved through more systematic collection of data, and critical attention to the development of management skills.

Finally, unlike other services, behavioral and mental health must contend with the negative perceptions steeped in centuries-old beliefs that are difficult to dispel. The stigma associated with mental illness finds employers, housing authorities, and other types of social systems, skirting the rules, and therefore confounding the ability of the system to effectively assist the mental health patient. Although these examples are difficult and persistent, it is important that countries recognize the issues and remain engaged in full scale strategic plans to deliver quality mental health care.