Making psychiatric epidemiology useful: the contribution of epidemiology to government policy

This paper aims to discuss the contribution of epidemiology to aspects of public policy that have either a direct influence on mental health and mental disorders, or an indirect effect by influencing environmental factors which influence mental health. Both kinds of public policy will need to be considered by governments wishing to protect, promote, and improve the mental health of their populations. The paper draws on information from both relatively wealthy and low-income countries. The paper defines epidemiology and mental health policy, sets out the range of government policies which may have an impact on mental health, and explores the ways in which epidemiology may contribute to mental health policy in relation to service inputs, processes and outcomes as well as to wider government policies. The paper also examines the advantages and disadvantages of different sources of data. There are a number of reasons to carry out large-scale surveys of psychiatric morbidity. First, effective policy should address the needs of the population, which can best be assessed by the epidemiology and the social and economic causes and consequences of psychiatric morbidity. Secondly, representative information in a defined geographic area can document the use of existing services and can estimate the extent of unmet needs and the services required meeting those needs. Thirdly, valid information on prevalence and associated risk factors of presumed causal importance allow aetiological hypotheses to be generated and tested and models developed for prevention. Finally, by repeating community surveys, it is possible to monitor the health of the population and trends. Epidemiological findings emphasize the importance of mental health policy addressing the key role of primary care, the social context and social consequences of disorder, the importance of addressing services for children, the need to reduce premature mortality from suicide and from physical illness. Epidemiological findings show that mental health and mental disorders are related to the environment both in its structural physical sense and in the sense of the social processes connected to and influenced by particular settings. Thus epidemiology can contribute to general policies on employment and unemployment, housing and homelessness, education, and women's issues. Mental health policy is increasingly recognized as an essential area for countries wishing to enhance their economic, social, and human capital. Epidemiological data are a basic prerequisite to informing such policies. Expert professional and epidemiological advice to ministries is essential if policy is to be rooted in the evidence for population needs, risk factors, effective treatments and services, and measurement of outcomes. It is therefore important to develop the capacity for policy work in the psychiatric profession by including public health, epidemiology, and policy placements for young psychiatrists.

The government's role in health care delivery

As Secretary of Illinois' largest agency, the Department of Human Services, Secretary Baker provides a thorough overview of the role her agency plays in the ongoing health and welfare of the citizens of Illinois. Her contention that government should play a critical role in health care delivery is buttressed by the DHS' role as a funding agent, its contributions of staff and systems, and the direct role it plays in the pursuit of truly public health care. Secretary Baker effectively demonstrates the complexities and disparities that still exist in health care by discussing an inter-generational study of one poor family documented in Chicago. She concludes, however, that while such disparities and injustices in health care delivery do exist, they can be overcome by the effective use and cooperation of state governmental agencies that are committed to that goal.

Brazil's mental health adventure

This is an account of my trips to Brazil in 2001 where I worked on a series of mental health projects with Brazilian colleagues. I first got interested in Brazil after I graduated from college when I was a Peace Corps volunteer in Northeast Brazil (Bahia state). After I got out of the Peace Corps I moved to Rio de Janeiro and went to work for United Press International (UPI) in their Rio bureau. I was UPI foreign news correspondent for a year and a half. Those years in Brazil were probably the happiest years of my life. Later on, after I became ill in the U.S., my Brazilian connection played an important role in my recovery. Raised in a Victorian family in a small town in the Midwest, and schooled in a traditional boarding school for boys and then at an all men's college, Brazil's lively Latino culture served as a healthy antidote for my tendency to be reserved and often depressed. My contact with Brazilians and Brazilian culture always beckoned me on. I maintained contact with my friends in Brazil and they stuck by me through my illness years. What seemed like my emotional and intellectual "excess" to me, was easily accepted by my Brazilian friends. I felt much more myself interacting with Brazilians and connected to a larger sense of self I developed in Brazil. I traveled to Brazil at every opportunity and made friends with Brazilians I met in the States. I initiated Portuguese classes at John Carroll University in Cleveland, Ohio in the early 1990s and then was invited to teach Brazilian culture to undergraduates. These appointments and my own resilience moved me past one depression and a dysthymia condition and into the wider community. I regained my confidence as a teacher, a role I had before and during the years of my illness. From this position, I organized a club for Brazilian students studying in the Cleveland area. After this teaching stint, I felt ready to pursue full time employment and began a job search that would eventually land me in New Haven at the Connecticut Mental Health Center. Since 1997, I've spent my vacations traveling and working in Brazil as an Outside Consultant on mental health projects with colleagues in Rio and Sao Paulo. In my travels I've been befriended and supported by adherents of a social movement, not unlike the U.S. Civil Rights Movement, that has struggled for many years to close Brazil's long-term psychiatric hospitals, create community-based services and expand the rights of mental patients. Now I see my Brazilian connection as part of my ongoing recovery. I see myself as having the opportunity to be a link between the mental health worlds of the U.S. and Brazil. I believe the two countries have much to offer each other when it comes to mental health.

The past, present and future of mental health law: a therapeutic jurisprudence analysis

This article uses a therapeutic jurisprudence perspective to review the evolution of mental health law in the Western world by examining developments at various stages in history, in particular the 20th century. It suggests that one of the major challenges for the future, from a therapeutic jurisprudence perspective, will be to help minimise the stigma, prejudice and discrimination associated with mental health law. The article concludes with the suggestion that the question of whether mental health law itself, because it contributes to discrimination against mentally disordered people, may be anti-therapeutic requires more investigation and consideration.

Waking Rip van Winkle: why developments in the last 20 years should teach the mental health system not to use housing as a tool of coercion

Many housing programs for people with mental illnesses rely on models that require the person to adhere to treatment as a condition of continuing access to housing. These models that 'bundle' housing and treatment are relics of a past in which persons with mental illnesses were afforded little real choice in treatment, housing and other social supports. Conditioning access to housing in this manner is coercive and at odds with current thinking regarding treatment, as well as legal principles that shape the environment in which treatment is provided. This article summarizes the reasons why housing for people with mental illnesses should be provided free of the use of coercion.

Using litigation to improve child mental health services: promises and pitfalls

Litigation against state governments has been one of the strategies to improve services for children with emotional and behavioral problems. The results of such litigation have been spotty in terms of expanding and improving services. Cases in North Carolina and Hawaii are used as examples of successful litigation that had substantial impacts, resulting in new, more appropriate services and expanded budgets. The similarities and differences in these two cases are discussed, as are the elements that appear to contribute to success and the risks associated with such litigation.