The Mental Health Care System And Its Components

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Mental health care should be an integral part of the overall health care system, its curative-medical, disease prevention and health promotion sectors. Many disease prevention programmes, such as obstetric care, the prevention of alcohol abuse and the containment of human immunodeficiency virus (HIV) infection, pursue both physical and mental health objectives. The same also holds for the treatment of frequent mental comorbidity in physical illness and vice versa. "Mental health is a vitally important aspect of public health that has long been segregated and neglected. . . . It is time to move mental health into the mainstream of health policy and practice" [6]. But this ideal of a closely intertwined physical and mental health care, which I consciously place at the beginning of this chapter, is not yet fully realized nor has it even always been intended in the past.

Recent population surveys have shown that mental disorders are highly prevalent in most countries throughout the world [7, 8]. In low-income countries, for lack of financial and human resources and because of "a very low priority of health-service policy" [9], mental health care is frequently neglected. But even in high-income countries with well-developed health care systems, such as the USA and Canada, "only a minority of mental patients receive adequate (and timely) treatment" (40% in the first year following illness onset) [8], although solid evidence exists that modern therapies are effective in treating the most commonly occurring mental disorders [8, 10]. An important reason for this is a widespread occurrence of delay in first help-seeking for single episodes [8]. The vast majority of recent-onset patients, even those who report substantial impairment associated with their disorder, receive first treatment more than a year and frequently even several years after the onset of the disorder.

Since age of onset of mental illnesses is inversely correlated with the delay in first treatment contact, as shown by the studies of Olfson et al. [11] and Kessler et al. [12], early-onset illnesses, frequently leading to lifelong disabilities at an early stage, are particularly slow to receive treatment. The Age, Beginning and Course (ABC) Schizophrenia Study [13] showed that in Germany, despite the availability of a tight network of health and mental health services, three-quarters of the cases of schizophrenia have a prodromal phase of an average length of five years and a psychotic prephase of one year before coming in contact with treatment services. It is in this early illness stage before first contact that most of the social consequences of schizophrenia manifest themselves [14].

Lack of knowledge of and negative attitudes of patients and their families towards mental disorders and their treatment facilities essentially contribute, in some countries more than in others, to the considerable delay in seeking help.

For this reason, mental health care means not only to encourage mentally ill people to seek treatment, but also to inform the patients, their relatives and the public about mental disorders and their treatment. The future of mental health care should offer outreach to these patients and improve early recognition of diseases for early treatment, whenever possible, because early intervention has the prospect of reducing early consequences of illness.

Cooperation in and coordination of mental health care actions are frequently indispensable not only between the providers of mental health care, but also with the providers of physical health care. Cooperation in an individual case, e.g., on the medical treatment of the pancreatitis of a person with alcoholism in psychiatric treatment, represents the lowest level of the system aspect. This level already makes plain the necessity for integrating various professions, diagnostic and treatment services in a multiprofessional enterprise comprising different specialities or disciplines. Examples are a large hospital or a network of community mental health services. That kind of multidisciplinary network of health care services, encompassing both preventive and rehabilitative components, is primarily aimed at maintaining and restoring the health of individuals.

The public health components of mental health care systems encompass multidisciplinary health promotive and disease preventive actions. As examples we can mention perinatal care and the prevention of AIDS, both associated with serious physical and mental health risks. Further determinants of mental health are the overall living conditions, including nutrition, education and safety. "Improving social conditions will inevitably improve the mental health status of a community," Gureje and Alem [9] state, writing about the living conditions extremely unfavourable for mental health in some African countries. "Wars and internecine strife disrupt social and community life and spread hunger, disease, and homelessness. These disruptions lead to psychological disorders" [9].

In many countries preventive health actions are not executed in cooperation with or by the mental health care system, but are taken autonomously within other sectors, such as the social services, the educational system or the field of agriculture.

WHO IS RESPONSIBLE FOR THE HEALTH CARE OF A NATION?

The History of Ideas of Health Care Systems

Mental health care systems frequently show characteristics that cannot be explained either by the current evidence for particular modes of treatment and care or the present economic state of a country. "Mental health services systems are typically shaped by historical tradition, political decisions and conventions of practice, financing and organization", Moscarelli and Rupp [15] write in their editorial to a special issue on mental health care. To be able to understand the role of these factors in mental health care systems, it is necessary to make a short excursion into the history of the social and political ideas and the economic conditions that have moulded health and mental health care systems.

Behind the current expectation that the state should bear responsibility for providing health care and compensation for the costs of illness and its consequences of any type there lies a long history of ideas. That history can be condensed into the answers to the question: what can governments do for the health of the people? In highly developed cultures it was early realized that there are health risks that only communities can successfully fight against as well as health risks that threaten the whole population [16]. Thriving economies like the medieval Mediterranean city states or 17th century England became aware of the fact that "the toll of illness and death meant great losses in productivity" [1].

The first attempts at translating these ideas into public action were preventive in nature: measures, such as quarantine, usually taken by port cities to protect their citizens by preventing epidemics from being brought in by ships' crews, rats and passengers. The reduction of food-related risks, as by meat inspection and garbage removal, has long, but very different traditions in the leading cultures around the world.

Decisive improvement in the health of most nations, reflected in continued reductions in infant mortality and increases in life expectancy, began to occur in the second half of the 19th century. The progress was triggered by the detection of asepsis and by research results in the field of medical epidemiology. Especially in Great Britain and Germany it was demonstrated how social conditions and infectious diseases such as tuberculosis and cholera were related. The four major risk factors mediating the association between social conditions and morbidity and premature mortality were poor nutrition, poor sanitation, and poor living and working conditions.

A decisive step was the discovery of the way some of these diseases spread—drinking water polluted with sewage—by the British physician John Snow during the cholera epidemics of 1849,1852 and 1853 in London. This epochal insight, followed in the subsequent decades by the discovery of the infectious agent and the ways of transmission of other major contagious diseases—tuberculosis, smallpox and diphtheria—and finally by active immunization against smallpox, unleashed in many countries enormous investments in the protection of drinking water, sanitation, garbage removal and nutritional hygiene.

The pace was almost breathtaking at which somatic medicine acquired numerous highly potent means of immunizing against and treating diseases. Well into the 20th century remarkable improvement in public health occurred in those countries that could afford protective public health measures and a fully developed health care system. With the advances in hygiene and medical science, the whole range of diseases changed: the classic epidemics and along with them the most frequent infectious diseases played an ever diminishing role in the morbidity spectrum of high-income countries. They were superseded by non-infectious, complex health risks particularly in the mental health domain, chronic diseases and behaviour-related health risks [17].

Until the present day the triumphant progress in physical medicine has been uninterrupted, challenged only recently by the emergence of new, unknown infectious diseases, such as AIDS, and the return of old epidemics, such as malaria and tuberculosis. At the same time, the number of physicians has increased rapidly and health expenditures have exploded in rich countries and also in some medium-income and developing countries.

In high-income countries health systems have grown into large economic complexes, devouring large proportions of national expenditures, on average 8-15% of the gross domestic product (GDP). In many countries they have become important, if not the main, providers of work.

It was probably the French social and state philosophers of the 18th century that had the greatest impact on making citizens' health and well-being a major duty of the state. As early as the late 17th century, Abbé Claude Fleury, tutor of Louis XIV's grandsons, proclaimed: "The main duty of the state is to preserve the health and morals of its citizens, to encourage population growth and prevent disease and crime'' (cited by Sand [18]).

Similar ideas are to be found in the works of Rousseau, Voltaire and Beaumarchais. They deem the state responsible for the health, morals and well-being of its citizens in a comprehensive way. In 1748, in his De ¡'esprit des ¡ois, Montesquieu wrote that the state should take care of the welfare of orphans, the ill and the elderly, but he also added that in a democratic state the citizens should also themselves contribute to a healthy living by education and self-education [19].

With the victory of the bourgeoisie, the French Revolution helped to spread the ideas of freedom, equality and fraternity in the population at large. Given the plight of the workers and their families in the early industrial age, the labour movement began to call for the state to step in as a compensator for the financial risk of illness. It is in this tradition, reflected in a series of resolutions of the United Nations (UN) and the WHO after World War II, that the social dimension of today's health and social insurance systems, under the earlier mentioned goal of fairness, is rooted. In continuance of this history of ideas there exist today the tax-financed national health care systems and state-run or state-controlled health and social insurance systems. They reflect the duty of the state to take care of its citizens by maintaining their well-being and health and by covering the economic consequences of ill-health.

The Liberal, State-Independent Tradition of Health Care

While the central-European tradition placed on the state the responsibility for providing socially and economically just health care, the early British political philosophers took a different, utilitarian approach. According to Nehemiah Grew's memorandum of 1707, the government had the duty to promote health and population growth, but merely in the interest of the nation. Sickness and death were regarded as leading to a loss of economic and national power and, thus, as public liabilities. The government was called on to preserve the health of its citizens, in order to increase the labour force and recruits for the army and in this way to enhance Britain's riches and power. This goal required first and foremost cheap labour. It was Joseph Priestley (1773-1804) who finally declared that the government should be released from the responsibility for the well-being and health of its citizens, because people, left on their own, would be capable of taking care of themselves and able to improve their living conditions from day to day. Thanks to this radical liberalism the riches and power of the British Empire grew, and the old, paternalistic ideal of solidarity and welfare fell into oblivion.

Originating in the belief in the blessings of relentless pursuit of self-interest, the extreme forms of liberalism and capitalism practised in Great

Britain were increasingly suffering from their own consequences: growing social distress, destitution of the working class, and epidemics and high mortality rates in the centres of merciless industrialization. For a long time, state action in the health care field was limited to providing rudimentary health and social care for the poor. It was not until a total change of system occurred, with the introduction of the National Health Service in 1948, that this tradition of radical liberalism came to an end in Great Britain.

The ideology of unlimited liberalism has survived in the USA, although not without undergoing several small-scale reforms. Almost 75% of the US population have to pay for the treatment and consequences of ill health out of their pocket or by prepaid fees to private insurance schemes. The government insurance schemes, such as the Veterans Administration, Medicare and Medicaid, provide—mostly only partial—health benefits to limited sections of the population, such as former service personnel, the elderly and the poor. Vast groups at risk, especially the chronically mentally ill, go unprotected with a risk of financial and social ruin in case of severe continued illness.

In the past two decades, with the aim of controlling or reducing costs in this, the world's most expensive health care system, a managed care system with private-enterprise health maintenance organizations (HMOs) was established in the USA. The HMOs, which make contracts with employers, physicians, hospitals and other health services, provide comprehensive health benefit plans for the employees of large companies and also of individual states. This market-oriented system, which has led to serious problems in mental health care—we will come back to them later—has become a model for a stepwise reform of the health care system in many countries and for bringing private-enterprise elements into state-run or solidarity-based health care systems.

Against the background of this brief history of ideas, we are today faced with two competing, though increasingly reciprocally influenced, value orientations in the existing health care systems. The one holds that the government alone is responsible for providing health and social care, according to the principle of fairness, as well as protection against the financial risk of ill health for the entire population. The other is the liberal tradition according to which state involvement in the health care sector should be kept to a minimum and individuals should pay for their health costs themselves. In the former case, health services are financed and run by government or private organizations, or by both; in the latter, health services are provided mostly by private enterprises, and large proportions of the population are left without adequate coverage.

Because of its basic incompatibility with the humanitarian and social values as expressed in the resolutions of various international organizations

(UN, European Union, etc.) as well as with the criterion of fairness as advocated by the WHO, the radically liberal tradition, especially as it does without a proper system of social care, has undergone some small-scale reforms. Nevertheless, the ideal of citizens' independence and a deep dislike of any form of governmental patronage, even with respect to health risks, are still widespread in the USA:

America is a land of individuals rather than cooperators, of unrepentant capitalists, of rugged entrepreneurs who get on by their own gumption or are left behind as failures. Americans are not without private generosity for those who fall by the wayside (so long as they are deemed worthy); but they dislike institutionalized generosity (epitomized by the old welfare system) that saps a man's will to heave himself up. [20]

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