Julio Torales

The WPA-Lancet Psychiatry Commission on the Future of Psychiatry

Background This Commission addresses several priority areas for psychiatry over the next decade, and into the 21st century. These represent challenges and opportunities for the profession to sustain and develop itself to secure the best possible future for the millions of people worldwide who will face life with mental illness. Part 1: The patient and treatment Who will psychiatrists help? The patient population of the future will reflect general demographic shifts towards older, more urban, and migrant populations. While technical advances such as the development of biomarkers will potentially alter diagnosis and treatment, and digital technology will facilitate assessment of remote populations, the human elements of practice such as cultural sensitivity and the ability to form a strong therapeutic alliance with the patient will remain central. Part 2: Psychiatry and health-care systems Delivering mental health services to those who need them will require reform of the traditional structure of services. Few existing models have evidence of clinical effectiveness and acceptability to service users. Services of the future should consider stepped care, increased use of multidisciplinary teamwork, more of a public health approach, and the integration of mental and physical health care. These services will need to fit into the cultural and economic framework of a diverse range of settings in high-income, low-income, and middle-income countries. Part 3: Psychiatry and society Increased emphasis on social interventions and engagement with societal expectations might be an important area for psychiatrys development. This could encompass advocacy for the rights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences. Part 4: The future of mental health law Mental health law worldwide tends to be based on concerns about risk rather than the protection of the rights of individuals experiencing mental illness. The United Nations Convention on the Rights of Persons with Disabilities, which states that compulsion based in whole or in part on mental disability is discriminatory, is a landmark document that should inform the future formulation and reform of mental health laws. An evidence-based approach needs to be taken: mental health legislation should mandate mental health training for all health professionals; ensure access to good-quality care; and cover wider societal issues, particularly access to housing, resources, and employment. All governments should include a mental health impact assessment when drafting relevant legislation. Part 5: Digital psychiatry—enhancing the future of mental health Digital technology might offer psychiatry the potential for radical change in terms of service delivery and the development of new treatments. However, it also carries the risk of commercialised, unproven treatments entering the medical marketplace with detrimental effect. Novel research methods, transparency standards, clinical evidence, and care delivery models must be created in collaboration with a wide range of stakeholders. Psychiatrists need to remain up to date and educated in the evolving digital world. Part 6: Training the psychiatrist of the future Rapid scientific advance and evolving models of health-care delivery have broad implications for future psychiatry training. The psychiatrist of the future must not only be armed with the latest medical knowledge and clinical skills but also be prepared to adapt to a changing landscape. Training programmes in an age in which knowledge of facts is less important than how new knowledge is accessed and deployed must refocus from the simple delivery of information towards acquisition of skills in lifelong learning and quality improvement. Conclusion Psychiatry faces major challenges. The therapeutic relationship remains paramount, and psychiatrists will need to acquire the necessary communication skills and cultural awareness to work optimally as patient demographics change. Psychiatrists must work with key stakeholders, including policy makers and patients, to help to plan and deliver the best services possible. The contract between psychiatry and society needs to be reviewed and renegotiated on a regular basis. Mental health law should be reformed on the basis of evidence and the rights of the individual. Psychiatry should embrace the possibilities offered by digital technology, and take an active role in ensuring research and care delivery in this area is ethically sound and evidence based. Psychiatry training must reflect these multiple pressures and demands by focusing on lifelong learning rather than simply knowledge delivery.

Intellectual disability and mental health: an overview†

ABSTRACT Characterised by impairment of global mental activities, intellectual disability as a term has replaced learning disability. Although in many countries terms such as mental handicap and mental retardation are still being used, the term intellectual disability is to be preferred. Intellectual disability has different significance across cultures and has three levels of severity: mild, moderate and severe. The causes of intellectual disability are divided into pre-natal, peri-natal and post-natal. Assessment and management of intellectual disability need broad multi-factorial approach. Rates of physical co-morbidity are very high and need careful evaluation.

WPA Position Statement on Recruitment in Psychiatry

The problem of recruitment in psychiatry is universal. There are very few countries where this problem does not exist. Variations have to be seen in the context of health care systems, training options and educational systems. The World Health Organization has set a target of one psychiatrist per 10,000 population globally. While this target is met in most European countries, North America and Japan, just under half of the world population live in countries with less than one psychiatrist/100,000 population. The rates are extremely low throughout Africa, and low in South America, Southeast Asia and Subcontinental Asia, with high urbanrural disparity. Despite the relatively high numbers of psychiatrists, many high-income countries are suffering from a perceived “recruitment crisis”. In many countries vacancy rates in training posts remain over 10%. To complicate matters further, often international medical graduates who may see psychiatry as popular take up much of the slack, contributing to “brain drain” from their countries of origin. Who chooses psychiatry, and what influences their choice? Many students choose medicine for the specific purpose of doing psychiatry, but some change their mind during their training. Others see the process through. Some students fall into psychiatry either passively or choose it actively. The reasons are often complex. Most of the studies have focused on understanding issues in Europe and the US. As duration of undergraduate training in psychiatry varies from 2 to 8 weeks, it is important to explore and understand these variations. WPA studies have shown that female doctors are slightly more likely to choose psychiatry. A personal or family history of mental illness increases the likelihood of choosing psychiatry. Medical students with undergraduate exposure to psychology or social sciences are more likely to choose psychiatry. Having a positive experience of psychiatry teaching and placement with clinical activities and exposure to psychotherapy during medical school, and/or additional exposure through clinical electives, also influence the choice of psychiatry. What factors negatively influence recruitment? A fall in levels of interest in psychiatry during undergraduate training can be attributed to poor exposure to teaching, a lack of psychiatric facilities and limited clinical exposure. Furthermore, the quality of mental healthcare in many parts of the world is extremely poor, and largely inpatient, with little opportunity for exposure to community-based psychiatry or other specialities. As such, students may be turned off psychiatry by what they witness during placements. The relative lack of financial reward can also affect career choice. Other factors are stigma against the psychiatric profession and against mental illness in general, resulting in perception of psychiatry as unscientific, ineffective, or apart from mainstream medicine. There is a perceived lack of respect from colleagues in other specialities and a poor public image. Furthermore, misconceptions and prejudices against the mentally ill themselves may make psychiatry an undesirable proposition. The stereotypes of psychiatric patients being dangerous or unpredictable and chronicity of psychiatric disorders can also put medical students off psychiatry. How can recruitment be improved?

Legal protection of the right to work and employment for persons with mental health problems: a review of legislation across the world

Abstract The right to work and employment is indispensable for social integration of persons with mental health problems. This study examined whether existing laws pose structural barriers in the realization of right to work and employment of persons with mental health problems across the world. It reviewed disability-specific, human rights legislation, and labour laws of all UN Member States in the context of Article 27 of the UN Convention on the Rights of Persons with Disabilities (CRPD). It wes found that laws in 62% of countries explicitly mention mental disability/impairment/illness in the definition of disability. In 64% of countries, laws prohibit discrimination against persons with mental health during recruitment; in one-third of countries laws prohibit discontinuation of employment. More than half (56%) the countries have laws in place which offer access to reasonable accommodation in the workplace. In 59% of countries laws promote employment of persons with mental health problems through different affirmative actions. Nearly 50 years after the adoption of the International Covenant on Economic, Social, and Cultural Rights and 10 years after the adoption of CRPD by the UN General Assembly, legal discrimination against persons with mental health problems continues to exist globally. Countries and policy-makers need to implement legislative measures to ensure non-discrimination of persons with mental health problems during employment.

Mental illness and the right to vote: a review of legislation across the world

Abstract The right to vote is an important right signifying freedom of thought as well as full citizenship in any setting. Right to vote is enshrined and protected by international human rights treaties. The right of ‘everyone’ to take part in the political process and elections is based on universal and equal suffrage. Although these International Conventions have been ratified by the large majority of United Nations Member States, their application across the globe is by no means universal. This study sets out to examine the domestic laws of UN Member States in order to explore whether individuals with mental health problems have the right to vote in actuality and, thu,s can participate in political life. Through various searches, electoral laws and Constitutions of 193 Member States of the United Nations were studied. The authors were able to find legislation and/or Constitutional provisions in 167 of the 193 Member States. Twenty-one countries (11%) only placed no restrictions on the right to vote by persons with mental health problems. Over one third of the countries (36%) deny all persons with any mental health problems a right to vote without any qualifier. Some of these discriminatory attitudes are reflected in the multiplicity of terms used to describe persons with mental health problems. Another 21 countries (11%) denied the right to vote to detained persons; of these, nine Member States specifically denied the right to vote to persons who were detained under the mental health law, while the remainder denied the right to vote to all those who were interdicted or judicially interdicted. It would appear that in many countries the denial of voting rights is attributed to a lack of ability to consent by the individuals with mental illness. Further exploration of explanation is required to understand these variations, which exist in spite of international treaties.

Legislative provisions related to marriage and divorce of persons with mental health problems: a global review

Abstract Realization of right to marry by a person is an exercise of personal liberty, even if concepts of marriage and expectations from such commitment vary across cultures and societies. Once married, if an individual develops mental illness the legal system often starts to discriminate against the individual. There is no doubt that every individual’s right to marry or remain married is regulated by their country’s family codes, civil codes, marriage laws, or divorce laws. Historically mental health condition of a spouse or intending spouse has been of interest to lawmakers in a number of ways from facilitating divorce to helping the individual with mental illness. There is no doubt that there are deeply ingrained stereotypes that persons with mental health problems lack capacity to consent and, therefore, cannot enter into a marital contract of their own free will. These assumptions lead to discrimination both in practice and in law. Furthermore, the probability of mental illness being genetically transmitted and passed on to offspring adds yet another dimension of discrimination. Thus, the system may also raise questions about the ability of persons with mental health problems to care, nurture, and support a family and children. Internationally, rights to marry, the right to remain married, and dissolution of marriage have been enshrined in several human rights instruments. Domestic laws were studied in 193 countries to explore whether laws affected the rights of people with mental illness with respect to marriage; it was found that 37% of countries explicitly prohibit marriage by persons with mental health problems. In 11% (21 countries) the presence of mental health problems can render a marriage void or can be considered grounds for nullity of marriage. Thus, in many countries basic human rights related to marriage are being flouted.

Disease versus illness: What do clinicians need to know?

The distinction between disease and illness is often not recognised clearly and both are seen as meaning the same. That may indeed be the case in colloquial terms, but confusion often exists in medical and certainly in psychiatric circles. Eisenberg (1977) very clearly and elegantly made the distinction between the two concepts. He defines disease literally as dis-ease, meaning that it deals with pathology, which is what doctors are trained to identify and manage. On the other hand, illness is what patients are interested in, as the impact of disease occurs on their functioning, relationships and social interactions. In an interesting aside, Eisenberg (1977) highlights the Cartesian mind-body dualism which was liberating at the time of its pronouncement but has become more restrictive over the centuries. This is particularly true in our understanding of the chasm perceived between physical and mental disorders. Eisenberg goes on to define illness as experience of disvalued changes in the state of being and in social function, whereas diseases – especially in the context of health care systems – are related to abnormalities in structures and functions both of body organs and body systems. The tension thus is between the patient perspective, which focuses on illness, and the doctor perspective, which often concentrates on diagnoses of diseases. This also means that illness experiences are treated in personal, folk and social sectors (Kleinman & Eisenberg, 2006). Thus, they argue that contemporary medical practice has become distant; with ever increasing technological advances such as mobile phone apps, this distance is likely to increase further not really decrease. They go on to caution that neither disease nor illness should be seen as distinct entities. Patients may find it acceptable to live with their symptoms as long as they are able to function and have relationships. The difficulties resulting from disease transformed into illness should not be separated clinically. Biomedicine appears to have banished the concept of illness. Using the same distinction of disease and illness in primary care, Helman (1981) highlights that the illness also includes the meaning given to the experience. Primary care physicians in a similar way to psychiatrists can understand the interface between the social and medical factors which can then be utilised in creating a common understanding as well as therapeutic alliance. Carel (2013, p. 94) points out that as the medical focus ignores concepts of illness and focuses on a negative deficit approach, the positive experience of health within illness remains unacknowledged. This is an observation which needs further exploration, as more individuals are living with chronic conditions and co-morbidities. Even within the context of psychiatry, if an individual has recurrent depression or bipolar disorder, it is worth remembering that in between the episodes, the individual may well be symptom-free. In her account of illness, Carel (2013) reminds us that the description of the lived experience as explained by phenomenology should be seen as a challenge to the medical world, which notes and deals with a different perception and description of disease in contrast with that of illness. Phenomenology undoubtedly places importance on a thoroughly human environment of everyday life and presents thus a view which is both personal and (therefore) novel. We know from clinical experience that no two patients will experience or explain their (somewhat) similar symptoms of hallucinations or delusions in the same way. Their explanation of what they are undergoing will vary according to their cultures, cultural world view and educational, social and economic status. Illness, according to Carel (p. 10), is not a biological explanation of dysfunction, but illness is a way of living, experiencing the world and interacting with other people; phenomenology attends to the global disruption of the habits, capacities and actions, and thus the focus has to be on the lived experience. Carel (2013, pp. 12–13) raises a very interesting point when she notes that in the past three decades or so, two approaches to illness have emerged. These are naturalistic (prevalent in the medical world where disease equates with biological dysfunction) and normativist (using common social terms to capture a particular phenomenon where the Disease versus illness: What do clinicians need to know?

Economic development does not improve public mental health spending

Abstract As a result of rapid globalization the Gross Domestic product of countries may have changed, but the gap between the very rich countries and poor countries has changed too, along with a change in social and economic strata within each society; although the rates of psychiatric disorders are affected by industrialization and urbanization, the financial pressures add yet another layer of burden. Global burden of disease due to mental illness is tremendously high and yet, in spite of pressures, there is no equity and increased discrimination related to mental illness. This paper presents some of the issues related to the economic state of the countries. In order to ensure that citizens receive the best treatments available it is important that socio-economic causes and gaps in treatment are identified and dealt with at national levels.

The right to health in Paraguay

Abstract Access to facilities, services and opportunities designed to meet the needs of health is a fundamental human right and is the key for people to enjoy other human rights. However, in Paraguay, this right is still far from becoming reality. The status of the country is the most disadvantaged when compared to the average condition of the Mercosur (Argentina, Bolivia, Brazil, Paraguay, Uruguay and Venezuela). Health, as a human right, expands as a social, economic, and political matter. Inequality, poverty, exploitation, violence and injustice are at the root of its poor quality and the consequent shortcomings that emerge from it. Access to health in Paraguay must be further developed using a human rights framework linking it with improving quality of life for all citizens. Such an approach means that potentially powerful barriers and interests must be questioned and contested wherever appropriate and that political and economic priorities must change drastically.

Right to property, inheritance, and contract and persons with mental illness.

Abstract Discrimination against people with mental illness is rife across the globe. Among different types of discrimination is the policy in many countries where persons with mental illness are forbidden to inherit property, and they are not able to enter into a contract in a large number of countries. Using various databases, legislations dealing with law of contract, law of succession/inheritance, and law relating to testamentary capacity (wills) of all UN Member states (193 countries) were studied. With respect to federal countries, the laws of the most populous state as a representative state in the respective country were studied. Only 40 Member States (21%) recognize/allow persons with mental health problems to enter into contracts. Of these, however, only 16 Member States (9%) recognize the right of persons with mental health problems to enter into a contract without any restrictions. The remaining 24 Member States (12%) allow a contract entered into by a person with mental health problems to be invalidated under certain conditions. These countries also make the validity of the contract subject to the capacity to consent or based on the level of understanding of the person with mental health problems. They may allow persons with mental health problems to enter into contracts only for transactions of an insignificant nature or of personal rights. Only 9% of the countries allow people with mental illness to enter into contracts in an unrestricted way. Furthermore, there remain variations between high income and low income states. In spite of international laws in many countries, laws remain discriminatory.