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in
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de
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give
a
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Le
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un
and
up-to-date
survev
of
the
bilan
concis
et
fiable
de
/a
present
position
in
the
.se-
.situation
actuelle
dans
le
X
u
p
a
tle
, ,
lected
fields,
and,
over
a
domaine
considere.
Des
ex-
period
of
Years,
will
cover
pert-s
couvriront
ainsi
su-
/
/
many
different
aspects
olf
cessivement
de
nombreux
the
biomedic
al
sciences
aspects
des
sciences
bio-
,
e
p
O|n
1
/
/t
arld
public
health.
M'ovs
oJ~
/
mtedicales
et
de
la
.sante
L e p
oint
the
articles
will
be
writ-
publique.
La
plupart
de
ces
ten,
bY
invitation,
bY
uc-
articles
auront
donc
e /
knowledged
experts
on
the
redig&s
sur
demande
par
les
subject.
specialistes
les
plus
autorises.
Bulletin
of
the
World
Health
Organization,
61
(I):
1-6
(1983)
World
Health
Organization
1983
Mental
health
in
the
early
1980s:
some
perspectives*
N.
SARTORIUS'
The
field
of
mental
health,
at
the
present
time,
has
an
important
potential
for
rapid
development.
The
reasons
for
this
include
important
new
knowledge
that
has
become
available,
increased
awareness
of
governments
about
the
size
of
mental
health
problems
and
about
the
importance
of
psychosocial
factors,
and
the
development
of
an
appropriate
technology
and
a
new
doctrine
of
mental
health
care
which
allow
useful
interventions
to
be
made,
even
when
financial
resources
are
extremely
scarce.
The
field
of
mental
health
has
never
had
a
greater
potential
than
in
the present
decade.
There
are
three
main
reasons
for
this.
Firstly,
over
the
past
few
years
there
have
been
a
number
of
most
encouraging
discoveries,
ranging
from
new
knowledge
about
the
viral
etiology
of
certain
mental
disorders
and
the
role
of
endorphines,
to
advances
in
the
behav-
ioural
sciences,
which
seem
to
have
entered
a
new
phase
of
creative
research,
inter-
pretation,
and
analysis.
Secondly,
many
governments
are
now
aware
that
the
mental
health
services
should
be
strengthened
because
they
could
significantly
help
in
the
provision
of
health
care
in
general.
Governments
are
worried
about
the
fact
that
medicine,
as
a
whole,
is
becoming
dehumanized
as well as
inefficient,
particularly
in
handling
the
large
numbers
of
patients
who
contact
health
services
with
ill-defined
but
persistent
complaints
that
cannot
be
directly
assigned
to
an
organic
lesion.
The
increase
in
the
number
of
persons
who
are
disabled
because
of
mental
disorders
or
as
a
result
of
psychological
components
of
general
disability
is
an
additional
grave
concern.
The
third
reason
why
mental
health
programmes
are
likely
to
gain
further
support
in
the
next
few
years
is
that
in
many
developing
countries
and
particularly
among
the
top
levels
of
leadership,
there
is
much
concern
about
the
social
and
psychological
consequences
of
rapid
economic
growth.
*
A
French
translation
of
this
article
will
appear
in
a
later
issue
of
the
Bulletin.
Director,
Division
of
Mental
Health,
World
Health
Organization,
1211
Geneva
27,
Switzerland.
4253
-1-
2
N.
SARTORIUS
A
NEW
SYNTHESIS
The
bitter
controversies,
fiery
arguments,
exhausting
discussions,
and
contradictory
tendencies
that
have
characterized
the
field
of
psychiatry
and
mental
health
in
general
over
the
last
twenty
years
or
so
seem
to
have
abated
and
to
have
been
resolved
peacefully.
It
has
gradually
been
recognized
that
institutional
treatment
is
necessary
for
certain
mental
disorders,
and
in
particular
at
certain
stages
of
their
development,
while
at
the
same
time,
community-oriented
services
have
now
gained
universal
support
even
in
countries
where
their
use
had
previously
been
completely
rejected.
Similarly,
care
for
the
mentally
and
the
neurologically
ill,
and
for
those
suffering
from
psychosocial
disorders
such
as
drug
dependence,
is
being
provided
more
and
more
through
general
health
services
without
resulting
-as
was
feared
-in
the
dismantling
of
the
system
of
specialist
mental
health
disciplines
which
is
necessary
to
create
the
technology
needed
for
mental
health
care
through
general
health
and
other
human
services.
There
has
also
been
a
resolution
of
the
controversy
about
the
need
to
apply
mental
health
knowledge
in
various
social
activities,
from
welfare
services
to
better
urban
planning.
The
need
to
apply
such
knowledge
has
found
recognition,
while
at
the
same
time
the
previously
exaggerated
aspirations
of
psychiatry,
to
deal
alone
with
all
phenomena
of
the
world,
from
poverty
to
war,
have
abated.
Close
collaboration
between
the
various
social
sectors
is
gradually
becoming
a
tenet
for
the
provision
of
mental
health
care,
without
the
earlier
tendency
for
the
activities
in
these
sectors
to
be
dominated
by
medical
professionals
and
behavioural
scientists.
A
number
of
countries
have
created
multidisciplinary
and
multi-
sectoral
groups
and
committees
for
the
organization
of
mental
health
care;
these
groups
contain
psychiatrists
but
are
not
dominated
by
them.
Another
controversy
that
has
been
resolved
is
that
concerning
the
relative
merits
of
centralization
and
decentralization.
It
has
become
fairly
well
recognized
that
the
central-
ization
of
resources
remains
necessary
for
research,
while
decentralization
of
responsibility
is
useful
for
the
provision
of
care.
The
fights
between
psychiatry
and
anti-psychiatry
are
losing
vigour,
at
least
in
Europe,
in
parallel
with
a
more
widespread
acceptance
of
the
need
for
humane
care
and
a
greater
respect
for
patients'
rights.
Another
argument
that
has
abated
in
many
countries
is
that
concerning
the
relative
priorities
of
research
and
of
investment
in
services.
It
has
been
generally
recognized
that
there
are
now
economically
and
socially
acceptable
techniques
of
treatment
that
are
effective
and
should
be
applied.
At
the
same
time,
a
vast
amount
of
research
still
needs
to
be
done
on
certain
topics
and
in
certain
areas.
Finally,
the
argument
about
the
applicability
of
"Western"
psychiatric
concepts
to
other
parts
of
the
world
seems
to
have
undergone
a
curious
reversal.
The
concepts
of
"Western"
psychiatry'
seem
to
be
becoming
more
appropriate
for
developing
countries,
East
and
West,
than
for
the
industrially-developed
parts
of
the
world.
Perhaps
this
is
because
in
many
of
the
developing
countries,
mental
health
services
have
now
reached
the
stage
of
development
of
the
mental
health
services
of
nineteenth
century
Europe,
in
which
the
concepts
of
"Western"
psychiatry
were
created.
Rapid
urbanization,
rural
depopulation,
redistribution
of
labour,
poverty,
hunger,
and
often
complete
apathy,
particularly
among
the
poor,
provided
the
background
to
the
growth
of
European
psychiatry;
these
conditions
provide
the
background
to
the
development
of
psychiatry
today
in
the
developing
coun-
tries.
Against
the
background
of
rapid
economic
growth
and
change,
one
saw
the
growth
of
institutions
in
which
were
assembled
those
who
were
mentally
ill
or
were
out
of
step
with
the
prevailing
society.
These
institutions
were
often
erected
primarily
to
provide
mental
patients
with
temporary
or
permanent
shelter;
soon
however,
they
became
overcrowded
a
"West"
and
"Western"
are
used
in
the
traditional
sense,
and
refer
to
developed
countries
of
Europe and
the
United
States.
MENTAL
HEALTH
and
unsuitable
for
humane
and
effective
treatment.
Dilapidated
buildings,
too
few
staff,
custodial
attitudes,
and
the
absence
of
any
prospect
of
regaining
freedom
no
doubt
contributed
to
the
types
of
behaviour
that
were
so
well
described
by
European
psychiatrists
in
the
nineteenth
century,
and
which
have
disappeared
from
better-run
institutions
nowadays.
The
scarcity
of
resources
in
Europe
at
that
time
also
contributed
to
the
characterization
of
these
mental
hospitals
as
a
point
of
last
recourse
for
violent,
aggressive,
and
intolerable
people.
Very
similar
economic
conditions
are
now
found
in
many
developing
countries
and
it
is
depressing
to
see
the
nameless
multitudes
of
mentally
ill,
destitute,
poor,
retarded,
and
physically
disabled
persons
roaming
the
courtyards
of
mental
hospitals
in
the
Third
World,
whiling
away
their
days
with
little
hope
of
treatment
or
of
release;
what
is
equally
depressing
is
the
scarcity
of
human
and
material
resources
available
to
effect
changes
in
the
health
care
system
-and
the
fact
that these
institutions
provide
the
psychiatric
training
for
the
general
and
specialized
health
personnel
who
will
handle
health
care
for
the
next
30
years.
The
situation
is
not
much
better
in
many
of
the
institutions
in
Europe
and
the
United
States
of
America
that
offer
training.
True,
the
physical
facilities
of
such
hospitals
are
better
but
the
atmosphere
and
way
of
working
and
managing
patients
is
still,
in
many
places,
such
that
trainees
not
infrequently
become
staunch
guardians
of
a
tradition
that
is
not
at
all
useful
for
the
conceptual
development
of
psychiatry
or
for
patient
care.
Another
factor
that
supports
the
applicability
of
early
European
concepts
of
mental
health
care
from
the
mid-nineteenth
century
to
today's
developing
countries
is
that
many
of
them
have
agricultural
economies;
this
has
much
to
do
with
the
selection
of
patients
who
come
to
hospitals.
In
an
agricultural
setting,
the
mildly
retarded
will
usually
have
a
place
in
the
community.
There
are
chores
that
they
can
do
quite
well
and,
though
mocked,
they
are
accepted
as
members
of
the
household
or
village
community.
It
is
only
the
very
severely
retarded-if
they
manage
to
survive-who
will
reach
the
hospital.
The
people
with
various
ill-defined
chronic
complaints,
who
plague
general
hospitals
and
health
services,
often
do
not
reach
the
mental
health
service
system
at
all.
They
get
no
further
than
a
traditional
healer
who
lives
close
to
them,
the
peripheral
health
station
or
the
pharmacy,
the
itinerant
dope
peddler,
or
some
other
person
who
is
willing
to
listen
or
to
give
some
sort
of
help
for
the
complaints
that
they
bring
forward.
Only
a
very
small
proportion
of
these
people
will
ever
be
seen
by
a
doctor,
and
an
even
smaller
proportion
will
reach
the
psychiatric
outpatient
services
or
hospitals.
Those
who
are
admitted
to
mental
hospitals
are
usually
taken
there
by
others-by
police
or
by
the
family-often
because
of
continuing
behaviour
that
disturbs
others,
regardless
of
whether
and
how
much
it
disturbs
the
patients
themselves.
A
second
category
of
people
admitted
to
mental
hospitals
are
the
"quietly
ill",
whom
traditional
healers
have
rejected
when
the family
can
no
longer
pay
the
healers'
often
exorbitant
fees.
Sometimes
such
patients
are
left
exposed
in
the
bush
or
disposed
of
in
some
other
traditional
way;
for
example,
they
may
be
chased
away
to
become
beggars.
Sometimes,
however,
the
family
decides
to
try
a
hospital
first,
particularly
if
the
cost
is
not
high.
A
NEW
DOCTRINE
OF
MENTAL
HEALTH
CARE
While
these
things
have
been
happening,
a
new
generation
of
mental
health
workers
has
emerged.
Many
of
them
are
in
developing
countries.
Through
accident
or
design,
because
of
the
necessity
and
because
of
humanitarian
striving,
they
are
creating
a
new
approach
to
psychiatry,
a
new
body
of
knowledge,
which
is
suitable
for
poor
countries,
and
could
3
4
N.
SARTORIUS
supplant
some
or
all
of
psychiatry
known
today
and
criticized
by
many.
This
new
doctrine
is
adjusted
to
facts
such
as
the
following:
in
many
countries
there
is
often
no
more
than
one
psychiatrist
per
million
population;
the
total
annual
health
budget
per
inhabitant
in
the
least-developed
countries
is
no
more
than
US$
1.70
and
US$
6
is
the
average
in
the
rest
of
the
developing
countries;
b
there
are
no
more
than
0.05
psychiatric
beds
per
thousand
population
(which
is
about
a
hundred
times
less
than
in
the
developed
countries);
the
supply
of
essential
psychotropic
drugs
is
poor
and
irregular;
and
the
education
of
general
health
personnel
does
not
include
any
notion
of
psychiatry
or
behav-
ioural
science.
Finally,
there
is
at
present
little
coordination
with
other
social
sectors,
although
these
services
might
contain
resources
that
could
be used
to
promote
mental
health
and
handle
mental
disorders.
What
is
more
important
is
that
this
doctrine
has
been
studied
and
it
seems
to
work.
In
a
World
Health
Organization
collaborative
study
undertaken
recently,
an
epidemiological
examination
of
areas
in
five
developing
countries
served
to
determine
the
most
frequent
problems
and
to
shape
the
training
of
general
health
personnel
who
were
to
deal
with
them.
This
training
was
provided
and,
although
the
evaluation
is
yet
to
be
completed,
it
seems
that
many
of
the
needs
of
the
severely
mentally
ill
can
be
covered
without
additional
staff
and
with
only
marginal
involvement
of
psychiatrists.
Several
recent
reports
from
other
studies
have
confirmed
these
impressions.
A
first
important
tenet
of
this
doctrine
is
decentralization
of
services,
and
provision
of
mental
health
care
by
people
in
the
general
health
care
service
who
have
an
active
interest
in
doing
so
rather
than
by
those
who,
often
by
curious
means,
have
been
designated
to
do
so.
A
further
part
of
this
doctrine
is
the
selection
of
a
small
number
of
essential
drugs
for
the
treatment
of
mental
disorders.
Extensive
consultation
and
examination
of
previous
results
have
shown
that
some
20
or
so
drugs
are
sufficient
for
the
entire
field
of
psychiatry;
no
more
than
two
or
three
of
these
are
needed
at
the
secondary
contact,
and
another
eight
or
so
at
the
level
of
tertiary
(specialist)
care,
usually
reached
through
referral.
The
background
tenets
of
the
new
doctrine
on
mental
health
care
are
of
particular
importance:
these
are
that
mental
health
must
be
seen
and
understood
as
a
concern
of
a
number
of
disciplines
and
social
sectors
rather
than
of
psychiatry
alone,
and
that
while
the
scope
of
mental
health
programmes
must
be
broad,
targets
and
goals
of
work
within
the
field
must
be
specific
and
clearly
defined.
Finally,
a
dominant
principle
of
the
doctrine
is
that
no
doctrine
is
good
enough
to
be
applicable
in
all
places.
The
components
of
the
doctrine
must
be
examined
before
they
are
applied
in
a
new
setting.
Once
the
components
have
been
tested
they
can
be
put
together
in
new
ways,
and
new
ones
can
be
added
as
necessary
to
make
valid
"modules"
that
will
be
useful
in
the
country
in
which
they
will
be
employed.
Such
evaluation
and
research
can
then
be
used
to
develop
appropriate
training
for
the
different
categories
of
personnel
involved
in
the
care
of
the
mentally
ill.
Directions
of
research
The
rebirth
of
a
useful
doctrine
for
mental
health
care
needs
to
be
accompanied
by
an
essential
reorientation
of
much
of
mental
health
research.
For
example,
it
would
be
valuable
if
cross-cultural
comparisons
concentrated
more
frequently
on
differences
within
the
researcher's
own
country.
A
look
at
changes
with
time
or
a
comparison
of
different
population
groups
living
in
the
same
location
blended
with
clinical
insights
and
epidemio-
logical
estimates
of
service
needs
could
help
both
science
and
those
concerned
with
service
development.
This
does
not
mean
that
collaboration
across
national
borders
is
unneces-
bAs
compared
with
a
per
capita
average
public
expenditure
of
US$
244
on
health
in
developed
countries.
MENTAL
HEALTH
sary;
on
the
contrary,
the
validity
of
findings
of
cross-cultural
research
within
countries
can
best
be
supported
by
comparison
of
results
of
work
done
by
researchers
using
equi-
valent
methods
in
their
own
settings
and
combining
their
efforts
to
understand
and
inter-
pret
their
findings.
Developing
countries
today
may
well
need
far
fewer
ethnopsychiatric
studies
than
before.
The
scarce
resources
could
probably
be
better
used
in
multidisciplinary
studies,
for
example,
of
service
organization,
of
the
response
to
psychotropic
drugs
in
different
countries,
of
protective
factors
preventing
the
development
of
mental
illness
in
people
living
in
very
difficult
situations,
and
of
the
role
of
the
family
in
conditions
of
rapid
socioeconomic
change.
Also,
there
have
been
few
studies
on
attitude
formation,
behaviour
modification,
and
decision-making
in
the
developing
world.
For
example,
almost
nothing
is
known
about
the
diffusion
of
health
information
in
urban
slums
in
developing
countries.
The
changes
in
attitude
formation
that
occur
in
rapidly
changing
socioeconomic
conditions
is
another
topic
deserving
attention.
Another
area
of
research
that
needs
development
is
that
concerned
with
the
functioning
of
services
under
different
socioeconomic
conditions.
Here
the
comparative
method
and
the
application
of
mental
health
and
behavioural
science
may
provide
particularly
useful
information;
in
most
countries,
such
comparisons
could
be
done
in
the
same
geographical
location.
A
CODA
ON
THE
CONCEPT
OF
MENTAL
HEALTH
Three
levels
of
definition
can
be
considered
in
defining
mental
health:
firstly,
that
mental
health
is
the
absence
of
any
well
defined
mental
disorder;
secondly,
that
mental
health
involves
a
certain
reserve
of
strength
in
an
individual
which
can
help
that
person
overcome
unexpected
stresses
or
exceptional
demands
and
challenges;
thirdly,
that
mental
health
is
a
state
of
balance
between
the
individual
and
the
surrounding
world,
a
state
of
harmony
between
oneself
and
others,
a
coexistence
between
the
realities
of
the
self,
that
of
other
people,
and
that
of
the
environment.
Such
a
state
of
balance
can
quite
clearly
incorporate
disability;
health
equilibrium
can
also
exist
in
the
presence
of
disease.
Health
and
disease
are
then
orthogonal
dimensions
of
existence
rather
than
real
opposites.
The
distinction
between
different
levels
of
definition
is
important
because
it
has
direct
consequences
for
the
future
of
research, for
the
composition
of
study
teams,
for
funding
decisions,
and
so
forth.
If,
for
example,
mental
health
is
seen
as
the
absence
of
disease,
our
teams
must
be
led
by
medical
doctors
because
they
have
been
trained
to
deal
with
disease.
Health
studies
must
deal
with
the
characteristics
of
treatments
and
include
standardized
assessments
of
the
well-defined
signs
of
well-described
diseases.
In
action-oriented
studies,
priority
must
be
given
to
the
prevention
of
disease,
or,
if
a
functional
or
structural
deficit
comes
into
existence,
to
its
localization
and
limitation
in
time
and
body
space.
If
the
definition
of
health
is
on
the
second
of
the
above-mentioned
levels,
then
persons
of
a
different
kind
would
become
the
team
leaders.
Psychologists,
physiologists,
and
ethologists
would
know
best
how
to
organize
the
teams,
and
the
studies
could
then
concentrate
on
how
individuals
and
groups
cope
in
specific
situations.
Study
instruments
would
have
to
include
ways
of
measuring
reaction
to
standardized
exposure,
to
exceptional
stress,
or
other
similar
features.
If
health
is
seen
as
a
state
of
balance,
other
conceptual
questions
have
to
be
tackled
first.
For
example,
it
would
have
to
be
decided
what
the
value
of
mental
life
is,
whether
it
is
incidental
to
human
existence
or
its
cause
and
purpose.
Societal
conceptions
and
ideologies
5
6
N.
SARTORIUS
then
become
central
targets
of
our
research;
social
scientists,
philosophers,
and
theologians
would
be
among
the
leaders
of
teams
that
would
carry
out
research
into
health
seen
in
this
way.
Mental
health,
so
defined,
becomes
much
more
intimately
linked
with
the
other
pursuits
of
societies
as
a
whole,
e.g.,
justice
in
social
relations.
No
doubt,
there
is
a
need
to
consider
all
three
levels
of
definition
when
future
strategies
of
research
in
behavioural
science
and
mental
health
are
being
considered.
This
is
difficult
but
necessary,
and
exemplifies
the
complexity
of
the
concepts
and
the
ambiguity
of
the
situations
in
which
we
have
to
carry
out
research,
teach,
and
organize
care.
