Figure 1. Mental health through governance1, 2, 4
Population mental health is an indicator of success of the policies developed by the governments and the co-responsibility among the members of the society. Mental health services must be based on multidisciplinary teams observing the international and national regulations for the generation of health strategies and policies based on current scientific knowledge that involves all health institutions, non-governmental organizations and civil society in order to dignify and respect the human rights of patients with mental disorders for their human development. This review expects to demonstrate the need of current public health policies on mental health and the necessary improvements by implementing strategies and policies in the primary medical care.
Keywords: Public Health, Health Systems, Mental Health, Mental Disorder, Governance
The human being is an entity made up of various dimensions at a genetic, biological, psychological and social level. It is based on learning and individual growth nourished by the family, the environment and the community, preserving its health as a means to achieve personal and collective fulfillment; therefore, population health is an indicator of the success achieved by society and its government institutions through governance (Figure 1).1, 2
Figure 1. Mental health through governance1, 2, 4
This allows to make decisions based on the patient's well-being supported by health information based on scientific evidence; essential to generate mental health laws, policies, programs and services, that must include the points of view of the health, education, government, justice and social development sectors in order to establish multidisciplinary strategies for their dissemination and ensure the co-responsibility between health services providers and users in compliance with international and national human rights documents for the protection of vulnerable and marginalized groups.3-5
In the case of the mentally ill the interaction between these dimensions is not balanced due to auto-rejection and family and community marginalization. The individualistic conceptual origin of mental illness under a biomedical approach of biological and brain-centered reductionism where personality, behavior, affections, emotions and thoughts are determined by physical causes, reduces the level of analysis of mental health to a merely biological topic, causing reciprocal suffering among their participants, since they ignore how to interact with each other. This leads to the use of disqualifying adjectives as well as to the restraint of public health institutions, family members and the community. Thus, public mental health policies are mostly focused on the biomedical care of the patient rather than on the holistic approach of mental health care which requires multidisciplinary groups.1, 6-8
Today, it is hard to listen to the mental health professionals, whether they are psychologists, physicians, psychiatrists and even other actors such as politicians, because of the use of disqualifiers to refer to the mentally ill. Now, the human rights of the patient, his or her social and labor inclusion, are recognized, granting the mental patient a status of guarantor of economic prosperity of a community; however, it is still common to find mental patients who are discriminated, stigmatized and limited in their access to health services and labor insertion, and the cuts to social protection programs that serve as a buffer against the effects of unemployment or persons with mental disorders cause a vicious circle of abandonment.6, 9, 10
The purpose of this article is to review the available information on the role of public health in the field of mental health and the current need of public health strategies and policies in the primary health care service for mental disorders.
After World War II, in countries like England, France and Germany, became necessary the emergence and prosperity mental health dynamics, specifically in the psychiatric discourse that talked about mental hospitals as the main way to deal with mental disorders, compared at that time with concentration camps. So, the post-Esquirolian doctrine arose, which intended to overcome the 1819 Esquirol definition that defined mental hospitals as the ideal treatment for mental illnesses.11
Long-term stays in mental hospitals, the lack of therapeutic attention, the marginalization of the mentally ill, the bureaucratization of institutions and the psychiatrist's conception of confinement as a primitive behavior of the community towards the mentally ill, are some of the reasons why Esquirol’s definition was questioned and a comprehensive vision emerged to deal with the community mental health through institutional psychotherapy based on the ideals of hospital mental hygiene and, on the other hand, the out-of-hospital psychiatric attention given in the community that allowed the participation of the government in the economic contribution, administration and management of mental health care services with the incorporation of the principles of public health.11
In this way, preventive psychiatry emerges aiming to reduce the frequency of mental disorders in the community, their duration and the deterioration that may result from them, referring to primary, secondary and tertiary care, based on the adequate number of highly qualified and conscious professionals with pedagogical training in the need to be, to do, to serve and to transcend in the minimum values with projection to the community through the conception of hospitals with open doors as described by Basaglia (1968) and taken up again in the Declaration of Caracas in 1990, which proposed integrating mental health care into the primary health care and local health care systems, aligned with the Mental Health Action Plan of the World Health Organization (WHO) 2013-2020.4, 9, 11, 12
The population’s perspective on public health, through its different connotations of public and collective governmental actions, as well as the prevention in marginalized groups, establishes that a priority topic is defined by its relevance, vulnerability (its feasibility to be intervened) and the capacity of the health care system to implement control measures.5
Therefore, the integral attention to mental health is an essential and main component of all the international agendas through government responsibility, prevention, treatment, care and rehabilitation in institutions that provide health care services as well as the economic responsibility of the State, private sector and citizens in such a way that it is possible to influence the individuals and the community by adjusting variables (Figure 2) like gender, socioeconomic status, education, culture and customs as well as the political and social communication frameworks, and the exercise of the patient’s rights.1, 3, 7, 8, 12-14
Figure 2. Variable adjustment in public health for health care systems1, 3, 7, 8, 12-14
The WHO affirms that an individual's mental health depends on the balance between physical, mental and social factors and not only on the absence of illness or the relationships that he or she establishes with others and his or her participation (Figure 3) to generate positive changes in his or her community. Mental illnesses in the world have different patterns, according to the national economic development, that must be tackled through holistic strategies in matters of prevention, health care promotion, treatment and rehabilitation, also as an area of research, professional action, political decisions, equitable distribution of resources, specific interventions and organization of health care systems.4, 8, 13
Figure 3. Health participation for the achievement of mental health and vice versa.4, 8, 13 WHO: World Health Organization.
In 1999, the European Conference on the Promotion of Mental Health and Social Inclusion highlighted the importance of primary health care by promoting mental health and the research on mental disorders.12
In 2012, at the 65th World Health Assembly, the resolution WHA65.4 was adopted. It mentions the global burden of mental illnesses and the emergency of having an international response. That is why it was generated a 2013 -2020 action plan on mental health which has among its goals that at least 80% of the countries have developed or updated their mental health plans by 2020 in accordance with international and regional documents. The plan also mentions the accessibility to mental health care through the universalization of health, human rights protection, planning of strategies and therapeutic interventions based on health care information taken from scientific evidence, attention to the life cycle of the patient (from breastfeeding to old age) to meet health and social needs, multisectoral attention with public and private participation, and the empowerment of people with mental disorders so they participate in developing strategies for mental health prevention, promotion and evaluation.4
The health systems are responsible for the quality of the health care services, the resources and the policies, however, today these health structures face a lack of human resources, infrastructure, drugs and non-pharmacological treatments as well as a hard bonding between the primary health care and the area of specialties.2, 4, 14
In the traditional model of medical care, the first contact of the patient with a mental illness is with the general or family practitioner, and later the patient is transferred to the psychiatry service, therefore, the primary health care is a key point for the diagnosis and follow-up of the patient. The problem lies in the minimum or no training at the primary health care to achieve a comprehensive diagnosis in such a way that most of the cases remain in the community isolated and without treatment.1, 3, 7, 15, 16
Therefore, the primary health care should implement strategies to promote mental health as well as to prevent disorders. This will reduce the incidence of organic diseases, saving lives and saving the money of patients and institutions, besides collaborating with different providers and levels of the health system, both formal and informal, and will promote self-care.4, 17
This will be possible through the bio-psychosocial approach by analyzing the determinants of population’s health, the training of the multidisciplinary team so they identify in a timely manner the main risk factors and the intersectoral link with other health institutions or institutions inherent to this problem that support the goals and indicators established in the annual work plans of the primary health care in order to ensure the mental well-being of all citizens.4, 17
Historically, the global prevalence of mental illness, costs and impact have been underestimated. Only in low and middle-income countries more than 70% of people with severe mental disorders have not received treatment even though international health organizations such as WHO and the Pan American Health Organization (PAHO) have recognized that they are an important public health problem and have asked governments and institutions to completely include mental health among their priorities; this implies a change in the affective attitude on behalf of the community and the health institutions in such a way that it is recognized that the mental health depends on the complete, equitable and effective access to the health care system, from a pregnancy and childhood attention, to the old age.1, 3, 4, 8, 9, 18
The prevention of suicide is one of the main priorities, the majority of the individuals who attempt it come from vulnerable and marginalized populations causing, by their self-injurious acts, a mental suffering to the actor and his or her community making necessary the recognition and early treatment of mental disorders and suicidal behavior as well as the availability of information for the analysis of suicidal risk by clinicians. This way the preventive value of mental health that depends on genetic influence, the harmonious interaction among family and the environment are an important piece that guarantees success in the complex human mind-organism link.4, 12, 19
Strategies for health promotion and prevention of mental disorders (Figure 4) during all vital stages can be based on policies against discrimination, stigmatization and human rights violations towards the mentally ill, the psychological attention in the early stages of life, detection, prevention and treatment of affective or behavior disorders; mainly in childhood and adolescence, implementation of healthy living and working conditions, programs or networks that fight against violence in the domestic or community environments, as well as the social protection of marginalized populations.4
Figure 4. Primary health care activities in mental health4
The epidemiology of mental disorders arises from three key points in history. The first phase corresponds to studies focused on the use of registers and informants to determine the prevalence in the population. The second phase occurs at the end of World War II when individual interviews to community samples emerge. Finally, through epidemiological measurement instruments used to identify specific mental disorders, together with the appearance of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and the International Classification of Diseases (ICD-10) that allowed the development of community-focused interview tools with specific diagnoses and nomenclature.16
In the world, mental illnesses are part of the epidemiological scenario and are the object of study of bio-epidemiology due to its tendency to chronicity, high prevalence, few treatments and high risk of causing disability.16
Its field of action is multifaceted and it is responsible for analyzing risk factors, design and sampling methods, the relationship between biological research, genetics and social disciplines, as well as the evaluation of treatments and services. The definition and selection of cases, controls, both exposed and unexposed, go beyond the traditional modalities of epidemiology and contribute in this way to the generation of knowledge for clinical psychopathology and the field of prevention.5, 16
Most of the epidemiological research is carried out through self-report, observation of conducts and cognitive evaluation of the patient. Therefore, the creation of measurement and evaluation tools for the analysis of mental disorders is fundamental for the epidemiological surveillance of mental illness, information for action, so it is necessary to train epidemiologists with knowledge in psychology and psychiatry as well as multidisciplinary teams at primary health care trained to identify the main risk factors, the appropriate management of the patient and the activities of epidemiological surveillance through the analysis and structure of the target or vulnerable population.14, 16, 17, 20
Today, the methodology of epidemiological research for the analysis of mental disorders is through the use of cross-sectional designs, cases and controls as well as those of cohorts enriched with the contributions of clinical and social psychology, and psychometrics. However, descriptive studies are still performed, mainly cross-sectional studies that consequently present important limitations and biases due to their design.16
The challenges that an increasingly complex epidemiological scenario presents will be based on the updating and creation of sophisticated measurement instruments based on technological advances, methodological efficiency with a causal and multidisciplinary approach, more emphasis on the use of case-control studies, study designs focused on the adolescent population and their linkage with biological, genetic and social research. 16
The WHO also urges the member States to calculate basic mental health indicators such as prevalence of mental disorders, identification of risk and protection factors (Figure 1), suicide and premature mortality rates, social and economic results such as level of education, access to housing, employment and income of people with mental disorders, all these broken down by sex and age as well as by geographical area.4
Public health and mental health have evolved at the same time, adjusting to the needs of the community and not of the individual, causing inequity, low scientific and technological development as well as the minimal or non-existent distribution of budgets assigned for health and the social protection of the mentally ill. The health care quality to ensure a mentally healthy population has the same importance as the biological health. However, it is still necessary to implement strategies and improvements in public policies for the development of programs and action plans aimed at the multidisciplinary care that must be provided to the patient with a mental disorder. The basis of these strategies is in the scientific research and the epidemiological surveillance as well as in the analysis of risk and protection factors that can ensure reliable and accurate information.
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[a] Department of Medicine, School of Health Sciences, Universidad Autónoma del Estado de Hidalgo. Ex Hacienda la Concepción s/n, Carr. Pachuca – Tilcuautla, C.P. 42060, Tilcuautla, Hgo., México.
Corresponding Author: Karla Valeria Suberbiel Ramírez. E-mail: valeria.alii29@gmail.com