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6InternatIonal PsychIatry Volume 11 Number 1 FebruArY 2014
thematic
paper
References
Basic Needs (2012) About us. At http://www.basicneeds.org/html/
about.htm (accessed October 2013).
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STRATEGIC DEVELOPMENTS IN THE DELIVERY OF
PSYCHIATRIC SERVICES WORLDWIDE
Mental health in Latin America and
the Caribbean
Jorge J. Rodriguez MD PhD
Senior Advisor on Mental
Health. Pan American Health
Organization/Regional Office of
the World Health Organization,
Washington, DC, USA,
email rodrigjo@paho.org
Saraceno, B., van Ommeren, M., Batniji, R., et al (2007) Barriers to
improvement of mental health services in low-income and middle-
income countries. Lancet, 370, 1164–1174.
WHO (2001) Mental Health: New Understanding, New Hope. World
Health Report. WHO.
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Available at http://www.who.int/healthinfo/global_burden_disease/
estimates_regional/en/index.html (accessed 15 October 2013).
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Care for Mental, Neurological, and Substance Use Disorders. WHO.
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Income Countries: A Who-Aims Cross-National Analysis. WHO.
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2013–2020. WHO. Available at http://www.who.int/mental_health/
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Mental Health 2000–2010 (AFR/RC49/9). WHO.
Mental illnesses are a growing health problem
and reducing the treatment gap in Latin
America and the Caribbean is a great challenge.
Evaluations conducted by the Pan American
Health Organization (PAHO) and World
Health Organization (WHO) have shown that
the responsiveness of health services is still
limited. Nonetheless, from an evaluation of
how mental health reform has progressed in
the region following the historical benchmark
of the Caracas Declaration (1990), it is clear
that – despite the limitations, shortcomings and
challenges – significant progress has been made
in most countries. This paper briefly reviews this
progress.
Mental illnesses are a growing health problem in
the Americas, as in the rest of the world. In 1990,
mental and neurological disorders accounted
for 8.8% of the total burden of disease in Latin
America and the Caribbean (LA&C), estimated
in terms of disability-adjusted life-years (DALYs).
This proportion had more than doubled, to 21%,
by 2006 (PAHO, 2009; Rodriguez et al, 200 9a,b).
A review of the most relevant epidemiological
studies of mental disorders conducted in LA&C
showed that, in recent years, the estimated average
prevalence rates in the adult population (meas-
ured during the preceding year) has been 1.0%
for non-affective psychoses, 4.9% for major depres-
sion and 5.7% for alcohol misuse or dependence.
It also revealed that more than a third of people
with non-affective psychosis, over half of those
with depression and about three-quarters of those
who were dependent on or misused alcohol had
not received any medical treatment, from either
specialised or general services (PAHO, 2009;
Rodriguez et al, 2009a, b).
In practical terms, this means that only a
minority of people who need mental healthcare
actually receive it. To this situation must be added
the fact that mental illnesses produce a high degree
of disability, and they particularly affect those in
the population who are most vulnerable, for whom
services are scarce (PAHO, 2009; Rodriguez et al,
7
InternatIonal PsychIatry Volume 11 Number 1 FebruArY 2014
2009a,b). Reducing this treatment gap is one of
the great challenges facing health systems on our
continent.
The response of programmes and
services
Evaluations of mental health systems, conducted
by the Pan American Health Organization (PAHO)
and World Health Organization (WHO) in LA&C,
showed that despite the magnitude of the burden
of mental disorders, the responsiveness of health
services is still limited. Here are some facts about
the availability of resources and the current situa-
tion of the programmes and mental health services
in LA&C.
The proportion of the health budget spent on
mental health, as an average in those evaluated
countries in the region, is less than 2.0% and 67% of
that budget allocation goes to mental hospitals. For
example, in six Central American countries and in
the Dominican Republic the review found that just
1.6% of the health budget is allocated to mental
health. Of that small proportion, no less than 75%
is allocated to mental hospitals. This illustrates
the need not only to increase financial resources
for mental health services, but also to update the
way in which those systems operate, with a shift to
out-patient, community services linked to primary
healthcare services (WHO, 2011; PAHO, 2012).
Of all the countries in the region, 66% have
a national mental health plan in place, of which
71% were formulated or updated after 2004. Also,
56% of countries reported having enacted mental
health legislation, although in many cases it needs
to be updated and adjusted to new technical and
human rights standards. The PAHO has identified
that in terms of policies, plans and legislation, the
crucial challenge is to achieve real and effective
implementation.
Thirty-eight per cent of the countries have
training programmes in mental health for
primary care physicians, and a similar propor-
tion have guidelines or protocols for the care of
people with mental disorders at the primary care
level. The median number of psychiatric beds per
10 000 population is 2.6, and these are distributed
in mental hospitals (45%), general hospitals (22%)
and residential facilities or ‘other’ (33%).
Fifty-two per cent of LA&C countries have
reported having at least one association of or for
users of mental health services, and 60% have an
organisation for families. This involvement of user
groups is an important contributor to the promo-
tion of social participation and particularly of
stakeholders in the formulation and implementa-
tion of mental health plans.
A final comment
The development of mental healthcare in LA&C
countries has faced various constra ints and difficu l-
ties in recent years. In response to this situation, a
conference on the restructuring of psychiatric care
in Latin A merica was held in Caracas, Venezuela,
in November 1990. This culminated in the
adoption of a continental initiative and launched
the Caracas Declaration, a document that made
history. The Caracas Declaration emphasised that
conventional care, focusing on the mental hos pital,
did not allow the achievement of the objectives
of modern mental healthcare – a community,
decentralised, participatory and comprehensive
approach to care, motivated by evidence-based
prevention (PAHO, 2009; Rodriguez, 2009).
Following the historical benchmark of the 1990
Caracas Declaration, it is clear that – despite the
limitations, shortcomings and challenges – sig-
nificant progress has been made in most LA&C
countries in the reform of services and the protec-
tion of the human rights of people with mental
disorders. Almost all now have better laws, national
plans and a vision of a community model of mental
healthcare linked to primary care and integrated
service networks. Similarly, there is greater aware-
ness, on the part of both governments and society,
of the challenges of mental disorders, and of the
treatment gap that still exists in the provision of
services, as well as of the stigma that surrounds
people with these conditions.
In October 2008, the WHO launched a pro-
gramme of action to bridge the gaps in mental
health. This aimed to scale up care for mental,
neurological and substance use disorders (through
the Mental Health Gap Action Programme,
mhGAP; WHO, 2008), based on the best available
scientific evidence.
In 2009, the PAHO Directing Council
adopted – with the consensus of participating
govern ments – the Strategy and Plan of Action
on Mental Health (PAHO, 2009), a milestone that
marks the way for the next 10 years. The Direct-
ing Council acknowledged there was a significant
burden of need in terms of mental disorders and
substance misuse and that a large proportion
of sick people do not receive any treatment. The
Council emphasised that there is no comprehen-
sive physical health without mental health.
Subsequently, the regional mental health con-
ference ‘20 years after the Declaration of Caracas’,
held in Panama in October 2010, issued a final
statement clearly stating an objective for the
region: ‘A continent without asylums by 2020’. This
was emphasised in the book Mental Health in the
Community, which was launched at the conference
(PA HO, 2010).
Technical cooperation in the PAHO is based
on the Regional Strategy (Rodríguez, 2009) and
mhGAP (WHO, 2008) and currently focuses on
five areas:
• the formulation and implementation of national
plans and mental health laws
• mental health promotion and mental disorder
prevention, with an emphasis on the psycho-
social development of children
• the organisation of mental health services in a
network linked to primary care (with definition
of priority conditions and implementation of
interventions)
8InternatIonal PsychIatry Volume 11 Number 1 FebruArY 2014
thematic
paper
• strengthening human resources
• strengthening the capacity to produce, evaluate
and use information about mental health.
Primary healthcare has become a key com-
ponent of a comprehensive mental health strategy,
with the aim of reducing the huge treatment gap
between need and delivery for mental health
problems in the region. Most people with mental
disorders cannot access care, and others who do
not need access to specialised care are subject to
overmedicalisation of their suffering, which can
be counterproductive. We are aware that most
people would benefit from comprehensive assist-
ance provided by a community health team and a
good social support network, and that is what we
are struggling to achieve within the next few years.
References
PAHO (2009) Strategy and Plan of Action on Mental Health.
49. Directing Council of PAHO, 61. Session of the WHO
Regional Committee for the Americas, from September 28 to
October 2, 2009 (Document CD49/11 and Resolution CD49.
R17). Pan American Health Organization. Available at http://
new.paho.org/hq/index.php?option=com_docman&task=doc_
download&gid=3653&Itemid= (English version) and http://new.
paho.org/hq/dmdocuments/2009/CD49-11-e.pdf (Spanish version)
(accessed 10 December 2012).
PAHO (2010) Panama Consensus. Pan American Health
Organization. Available at http://new.paho.org/hq/index.
php?option=com_content&view=category&layout=blog&id=1167&
Itemid=353&lang=en (accessed 10 December 2012).
PAHO (2012) WHO-AIMS sub-regional and country reports
available on the PAHO website, at http://new.paho.org/hq/index.
php?option=com_content&task=view&id=445&Itemid=1106%20
&lang=en (accessed 10 December 2012).
Rodríguez, J. (ed.) (2009) Salud Mental en la Comunidad. Serie
PALTEX para Ejecutores de Programas de Salud No. 49 OPS/OMS.
Pan American Health Organization.
Rodriguez, J., Kohn, R. & Aguilar-Gaxiola, S. (2009a) Prevalence
and burden of mental disorders in the adult population of Latin
America and the Caribbean. In Epidemiology of Mental Disorders
in Latin America and the Caribbean, pp. 19–32. Scientific and
Technical Publication No. 632. Pan American Health Organization.
Rodriguez, J., Kohn, R. & Aguilar-Gaxiola, S. (2009b) Use of
mental health services and the treatment gap in Latin America
and the Caribbean. In Epidemiology of Mental Disorders in Latin
America and the Caribbean, pp. 300–315. Scientific and Technical
Publication No. 632. Pan American Health Organization.
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10 December 2012).
STRATEGIC DEVELOPMENTS IN THE DELIVERY OF
PSYCHIATRIC SERVICES WORLDWIDE
Together to make a difference in mental
health in the Western Pacific Region
Xiangdong Wang
Mental disorders are among the leading
causes of disease burden in the Western Pacific
Region of the World Health Organization
(WHO). Networking and partnership have been
identified as the major components of key
strategies to address challenges in meeting
mental health needs in the region. This article
provides a brief review of relevant initiatives
collaboratively developed by the WHO, member
states in the region and other partners.
Mental disorders are among the leading causes of
disease burden worldwide. Depressive disorders
alone are responsible for 5.73% of the global burden
of disease in the Western Pacific Region of the
World Health Organization (WHO). About a third
of all suicides in the world are reported from the
region. At the population level, there are common
factors that have a negative impact on mental
health in many member states. These include
disaster proneness, rapid population ageing and
dramatic changes in social norms and values that
have accompanied globalisation and substantial
socio economic development. It has been a consen-
sus of health ministers that mental health issues, if
not addressed appropriately and immediately, will
continue to grow. They will have an adverse effect
on the health of people in the region and on overall
socioeconomic development as well.
Team Leader, Mental Health and
Injury Prevention, WHO Western
Pacific Regional Office,
email wangx@wpro.who.int