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1. What is the problem/gap you are trying to solve. Identify the need and consider context (political/socio-cultural).
- Problem/Gap: Helping adults with anxiety overcome their anxiety through exercise
- Need: There are many adults who suffer from anxiety, which impacts their daily function
- Context (political/socio-cultural):
- Political Context: Private healthcare
- Socio-cultural: Inner-city London area

2. How does the intervention impact on this problem/gap. Consider benefits and results.
-  Impact of Intervention: Exercise has been proven to help adults manage and reduce their anxiety. Our intervention could be yoga/meditation and/or mindfulness training.
Benefits: Give service users tools needed to manage anxiety on their own time, in between sessions
Results: Increased ability to manage own anxiety levels

3. What is the USP of this intervention. What makes it unique? 1 or 2 key facts. Do not over-claim.
- USP (Unique Selling Point) of Intervention: This program would be different to other "exercise programs" because it would focus on mindfulness and awareness of the body and  will help the service user learn tools to bring awareness to the root cause of the anxiety, and hopefully, learn to handle their anxiety effectively.
- This intervention is incredibly flexible on where it can be conducted, plus it is incredibly cost-effective, as for basic poses, all you would need is your body and a big enough room.
- 1 or 2 Key Facts:  Based on our research, exercise has been shown to reduce the symptoms of anxiety.

4. The intervention should have an OT focus (e.g function/ occupation).
- Intervention Which is OT-Focused: Could be something like yoga/meditation and mindfulness - this would be OT-focused by giving the service user the tools needed to combat their anxiety symptoms in their daily lives by teaching them how to combat their symptoms with intrinsic methods (i.e., breathing exercises, meditation, yoga sequences, etc.)

The pitch should be:
- Concise (3mins)

- Easy to understand

- Memorable

- Convincing

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Conceptualising participation  in physical activity within MOHO

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Conceptualising participation  in physical activity within MOHO

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Facilitators and Barriers of exercise participation for those with ARDs

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Facilitators and Barriers of exercise participation for those with ARDs

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Effects of an exercise programme on anxiety in adults with intellectual disabilities

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Effects of an exercise programme on anxiety in adults with intellectual disabilities

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Exercise for anxiety disorders: systematic review

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Background Anxiety disorders are commonly treated with antidepressants and psychological treatments. Some patients may prefer alternative approaches such as exercise. Objective To investigate the treatment effects of exercise compared with other treatments for anxiety disorders. Data sources Randomised controlled trials (RCTs) of exercise interventions for anxiety disorders were identified by searching six online databases (July 2011).

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Cognitive Behavioural Therapy (CBT) for anxiety in adults with intellectual disabilities. 

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Cognitive Behavioural Therapy (CBT) for anxiety in adults with intellectual disabilities. 

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Cognitive Behavioural Therapy (CBT) for adults with anxiety

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Cognitive Behavioural Therapy (CBT) for adults with anxiety

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Regular exercise, anxiety, depression and personality: A population-based study

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To examine whether regular exercise is associated with anxiety, depression and personality in a large population-based sample as a function of gender ...

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Effects of physical exercise on anxiety, depression, and sensitivity to stress: A unifying theory

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Until recently, claims for the psychological benefits of physical exercise have tended to precede supportive evidence. Acutely, emotional effects of e...

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Physical Activity, Exercise, Depression, and Anxiety Disorders

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Reducing Anxiety Sensitivity with Exercise

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The mental health of US Black women: the roles of social context and severe intimate partner violence

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The mental health of US Black women: the roles of social context and severe intimate partner violence

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Mental illness and the developing world | Andrew Chambers

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Andrew Chambers: Mental and neurological disorders are the leading cause of illness, but international development virtually ignores them

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William and Kate's Mental Health promoting

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William and Kate's Mental Health promoting

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Heads Together | Join the conversation | Mental Health

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Heads Together work to ensure that people feel comfortable with their own and their friends and family everyday mental health and well being.

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The Mental State Examination (MSE) is a tool used to assess individuals in the hospital/community mental health services as an observational tool.

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Recovery college | from mental health patient to recovering student. 

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Recovery college | from mental health patient to recovering student. 

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Recovery college | The Health Foundation

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The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. Find out more about us.

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Improving the care experience for people using adult mental health services. 

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Improving the care experience for people using adult mental health services. 

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Challenges and opportunities in Global Mental Health

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Challenges and opportunities in Global Mental Health

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This paper enumerates and briefly discusses WHO's recent contributions to global mental health and the current challenges and opportunities in this area. It briefly discusses response to diversity across countries and communities, the need for innovations and global exchange of information, evidence and knowledge and raises issues like psychological interventions and human rights related to mental health.

*Address for correspondence: Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland. (Email: saxenas@who.int)

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Challenges and opportunities in global mental health: a perspective from WHO | Epidemiology and Psychiatric Sciences | Cambridge Core

# data[].attributes.attachment_link.description
This paper enumerates and briefly discusses WHO's recent contributions to global mental health and the current challenges and opportunities in this area. It briefly discusses response to diversity across countries and communities, the need for innovations and global exchange of information, evidence and knowledge and raises issues like psychological interventions and human rights related to mental health.

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Mental Health disorders, health inequalities and ethics

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Mental Health disorders, health inequalities and ethics

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Abstract

The global burden of neuropsychiatry diseases and related mental health conditions is enormous, underappreciated and under resourced, particularly in the developing nations. The absence of adequate and quality mental health infrastructure and workforce is increasingly recognized. The ethical implications of inequalities in mental health for people and nations are profound and must be addressed in efforts to fulfil key bioethics principles of medicine and public health: respect for individuals, justice, beneficence, and non-malfeasance. Stigma and discrimination against people living with mental disorders affects their education, employment, access to care and hampers their capacity to contribute to society. Mental health well-being is closely associated to several Millennium Development Goals and economic development sectors including education, labour force participation, and productivity. Limited access to mental health care increases patient and family suffering. Unmet mental health needs have a negative effect on poverty reduction initiatives and economic development. Untreated mental conditions contribute to economic loss because they increase school and work absenteeism and dropout rates, healthcare expenditure, and unemployment. Addressing unmet mental health needs will require development of better mental health infrastructure and workforce and overall integration of mental and physical health services with primary care, especially in the developing nations.

Introduction

The burden and inequalities in mental healthcare throughout the world are critically important health issues, and taken together present immense ethical challenges. In this paper we examine mental health issues globally, with special emphasis given to the developing nations, because of the limited research and increased burden of mental disorders in these nations. We also provide an overview of the ethical considerations in international mental health and renewed interest in approaches that integrate mental health into primary care services ().

Table I

Burden of mental disorders

The global burden of mental disorders is enormous, under-appreciated, and largely unmet.

Annually, about 30% of the population worldwide is affected by a mental disorder and over two thirds of those affected do not receive the care they need. Depression, alcohol and substance abuse and psychoses are among the most prevalent conditions.

Mental health problems have major economic and social cost.

Many nations have limited capacity (e.g. infrastructure, workforce, resources) needed to assess, identify and treat mental health disorders.

Ethics, human rights and social justice

Human rights and social justice frameworks are critical in understanding and addressing mental health inequalities.

In many nations, limited or no policies exist to address basic needs and human rights of people with mental illness and standards of ethical conduct of research and treatment of mental disorders are inadequate or lacking.

Ethical principles of beneficence, autonomy, respect for persons and non-malfeasance for people living with mental disorders foster human dignity, and promote human rights and social justice.

Mental health inequalities and unmet needs

Mental disorders are associated and embedded within the broader social and economic context.

Poverty increases the risk of developing mental disorders, which in turn increase the risk of living in poverty due disability or loss of gainful employment.

Mental disorders are determined by multiple and interacting social, psychological and biological factors. The underlying social determinants of mental disorders (e.g. low levels of education, unemployment) also are key determinants of living in poverty.

Unmet mental health needs contribute to profound suffering and deaths largely because people cannot access needed treatment.

Shortage of mental health providers and resources result in unnecessary institutionalization of people with mental illness even though these conditions can be managed effectively in the community if services were available.

In most developing nations, the burden of caring for people with mental illness disproportionately falls on women and children.

Stigma and discrimination

Mental health stigma and discrimination are major barriers to effective management of mental disorders.

Stigma, myths, and misconceptions of mental illness contribute to much of the discrimination and human rights violation experienced by people with mental disorders.

Stigma and discrimination increase social isolation and unmet needs for mental health services, negatively influence choice of mental health careers, and limit development of policies and human rights protections for people living with mental disorders and their families.

Limited access to modern psychiatric services increase beliefs that mental disorders are untreatable which further increases stigma and discrimination and patient's reliance on traditional healers who may not have adequate skills and training to help people with serious mental disorders.

Integration of mental health into primary health care services

In many developing nations, mental health services are provided at the tertiary level with limited or no integration to primary care interventions.

The majority of individuals with mental disorders and their families live in overt poverty and cannot access, afford, appropriate and available specialized mental health services provided at tertiary levels health facilities serviced by psychiatrists.

Extreme and growing shortage of mental health workers further compounds the problem of access to mental health services resulting in limited access to services and reliance on traditional healers in some nations.

In the absence of integrated proper functioning health systems it is impossible to provide mental health services for most individuals with mental disorders and their families in developing nations.

Integrating mental health into primary care services is a critical, affordable, and cost-effective approach to delivering services for people living with mental disorders.

Such integrated systems of primary care can reduce unmet needs and social stigma and discrimination by decreasing social isolation, neglect, and institutionalization of people with mental disorder.

Impact on economic development

The economic burden of mental disorders is great. Mental disorders significantly impair economic growth through their effects on labour supply, earnings, participation, and productivity.

Unmet mental health care needs are associated with increased risk of social problems (e.g. school drop out, alcohol and drug use, disability, unemployment, unsafe sexual behaviours, crime and poverty) that may influence economic growth.

In many developing nations, limited efforts have been made to address or modify the social determinants of health, including actions that allow people to adopt and maintain healthy life styles and those that create living conditions and environments that support health.

Mental health promotion is an integral part of health promotion theory and practice where persons with mental illness need affordable, available, accessible, and appropriate sustainable mental health services for them to continue education (children and youth) or remain in an economic sustaining livelihoods (employment).

These associations play a major role in risk behaviours, such as unsafe sexual behaviour, road trauma and physical inactivity resulting in lack of meaningful, or dismissal from, employment, and in turn becomes an associated cause for depression and alcohol and drug use among people with mental disorders and their families.

Mental health data

Lack of reliable mental health data within and across nations is pervasive and a critical barrier in addressing unmet mental health needs.

Limited data hinder better understanding of mental health needs, limit policy, interventions, and resources needed to address mental disorders.

Data limitations put mental health needs on the back burner of policy development and resource allocation.

Better collection of mental health data are needed in the developing nations and among rural and racial groups in developed nations.

Mental disorders account for an enormous global burden of disease that is largely underestimated and underappreciated. In a given year, about 30% of the population worldwide is affected by a mental disorder and over two thirds of those affected do not receive the care they need ( Chisholm et al., 2007; Kessler et al., 2005b; Wittchen, Jonsson, & Olesen, 2005). About 14% of the global disease burden is attributed to neuropsychiatric disorders, mostly depression, alcohol-substance abuse and psychoses ( Murray & Lopez, 1996; Prince et al., 2007). In the USA, about 57.7 million adults experience a mental disorder annually, and 1 in 17 people have a serious mental health condition ( Kessler, Chiu, Demler, & E.E., 2005a). These figures translate into hundreds of millions of people suffering from mental disorders globally including depression (154 million), schizophrenia (25 million), and alcohol use disorders (91 million) ( Schmidt, Norman, & Boshuizen, 1990; WHO/WONCA, 2008). Suicides account for about 1 million deaths annually ( WHO, 2002).

The projected burden of mental health disorders is expected to reach 15% by the year 2020, where common mental disorders (depression, anxiety, and substance-related disorders including alcohol) will disable more people than complications arising from AIDS, heart disease, traffic accidents and wars combined. Almost one third (28%) of disability-adjusted life-years in 2005 were attributed to neuropsychiatric disorders (e.g. unipolar affective disorder (10%) ( Murray & Lopez, 1996).

The burden of unmet mental health needs is especially high among children and youths ( Flisher et al., 1997; Kataoka, Zhang, & Wells, 2002; Ngui & Flores, 2007). About 10% to 20% of all children are affected by one or more mental or behavioural problems ( Murthy et al., 2001). In the USA, 1 in 5 children suffer from a mental disorder, with 1 in 10 affected by a serious mental or emotional disorder ( US Department of Health and Human Services, 1999). Only 15% to 30% of these children, however, receive the treatment they need ( WHO/WONCA, 2008). Kataoka found that 79% of children 6 to 7 years of age with mental disorders do not receive the care they need ( Kataoka et al., 2002). Data from the developing nations is less reliable, but estimates from the Western Cape region of South Africa suggest that 17% of children and adolescents suffer from mental disorders ( Kleintjes et al., 2006), whereas in conflict areas such as Mosul, Iraq it is as high as 35% of children and youths ( Al-Jawadi & Abdul-Rhman, 2007).

In light of this evidence, the ethical concerns associated with international mental health disparities are profound. Human rights and social justice frameworks are arguably central ethical tenets of public health ( Beauchamp, 1999). According to the International Covenant of Economic, Social and Cultural Rights, 'everyone has a right to the highest attainable standard of physical and mental health' ( Earle, 2006, p. 327). As such, addressing global mental health inequalities and the underlying determinants of mental disorders promotes human rights and social justice in any society. These frameworks call for the ethical care of people living with mental illness and global advocacy of beneficence, autonomy, respect for individuals, non-malfeasance and empowerment of all people, and particularly those who are marginalized, stigmatized and discriminated against ( Roberts & Dyer, 2004; Sheppard, 2002). Paul Farmer observes that the needs of the world's poor are often not recognized and the underlying structural inequalities that contribute to these conditions are frequently neglected or ignored by the international public health and foreign policy communities ( Farmer, 2003). He calls for the inclusion and integration of human rights agenda, including resource equity and social justice in health diplomacy and international health assistance ( Mann, 1996).

Initiatives and strategies to address health must systematically incorporate mental health as a key part of overall health. Application of the human rights and social justice frameworks in mental health require concerted effort and commitment to address the underlying determinants of mental health problems including fair, equitable, and ethical distribution of resource distribution (e.g. treatment), inclusive mental health and primary care policies, and strengthened legal and human rights protection for people living with mental disorders and their families.

In many developing nations, standards for ethical conduct of research and treatment are inadequate or lacking. Addressing inequalities and unmet mental health needs, especially in the developing nations, will require establishment and strengthened ethical standards in research and treatment of people with mental health problems. Goodman (2008) observes that 'ethics is essential for building trust in developing world ... ethics and trust are required for a successful research programme ... health of communities depends on more and better research; and that such research is necessary for reducing disparities' ( Goodman, 2008, p. 89). Indeed, repeated demonstrations of integrity by economically established countries towards all people affected by mental illness and its burden throughout the world is a precondition for ethically sound and humane healthcare. Moreover, intensive and more appropriately attuned ethics education is critically important in understanding and addressing mental health inequalities and in the preparation of clinicians caring for people living with mental illness ( Chipp et al., in press; Hoop, DiPasquale, Hernandez, & Roberts, 2008; Jain, Dunn, & Roberts, in press; Lehrmann, Hoop, Hammond, & Roberts, 2009; Roberts, Johnson, Brems, & Warner, 2008) in rural and underserved areas.

Inequalities in mental health

Inequalities in mental health exist, are pervasive and often ignored as illustrated by the neglect of a mental health focus in the Millennium Development Goals ( United Nations, 2000). According to the World Health Organization (WHO), health inequalities can be defined as 'differences in health status or in the distribution of health determinants between different population groups' ( WHO, 2007). Health inequity is those inequalities in health considered unfair and unjust ( Kawachi, Subramanian, & Almeida-Filho, 2002). Inequity in mental health exists in access to care, use and outcomes of care (e.g. morbidity and mortality) and can occur by geographical region (rural/urban), gender, socioeconomic status, racial or ethnic background and sexual orientation among other things.

Mental health inequalities are strongly associated and embedded within the broader social and economic context. An inverse relationship between socio-economic status and mental disorders has been documented ( Dalgard, 2008; Hunt, McEwen, & McKenna, 1979; Kessler et al., 1994). In almost all nations the poor are at a higher risk of developing mental disorders compared to the non-poor. Poverty, is both a 'determinant and a consequence of poor mental health' ( Murali & Oyebode, 2004, p. 217). Mental disorders increase the likelihood of living in poverty, perhaps because of their influence on functionality and ability to get or sustain employment. Conversely, poverty increases the likelihood of developing mental disorders ( Bostock, 2004; Das et al., 2007; Murali & Oyebode, 2004).

The consequences of mental health inequalities include continued unnecessary suffering and premature deaths, increased stigma and marginalization, lack of investment in mental health workforce and infrastructure, and limited or lack of treatment for people suffering from these conditions. In many developing nations with mental health policies, scarce resources and infrastructure, ineffective advocacy and the lack of political will limits effective mental health legislations and interventions ( WHO, 2005b). These nations often lack effective mental health champions who can galvanize communities and policy makers to address mental health needs. Families of people with mental health problems are often marginalized and are limited in their ability to champion for mental health issues due to the stigma associated with these disorders. Some progress, however, is being made redress the challenges posed by mental health problems ( Eaton, 2009), but these efforts are few and need to be scaled up to adequately meet mental health needs.

Unmet mental health needs

Mental health inequalities have contributed to profound suffering and death worldwide largely because people cannot access the treatment they need. Estimates for untreated serious mental disorders in developing countries range from 75% to 85% ( WHO, 2004). Over 80% of people suffering from mental disorders (e.g. epilepsy, schizophrenia, depression, intellectual disability, alcohol use disorders and those committing suicide), live in developing countries ( Bertolote, Fleischmann, De Leo & Wasserman, 2004). Untreated cases range from 32.2% for schizophrenia (including other non-affective psychosis) to 56.3% for depression, to 78.1% for alcohol and drug use disorders ( Kohn, Saxena, & Levav, 2004). In Kenya, for example, the number of unidentified cases of mental illness attending a National Hospital was 40% ( Makanyengo, Othieno, & Okech, 2005); with unidentified cases of depression between 53% and 66.2% at the sub-district and district hospitals, respectively. Almost a quarter of patients attending general health facilities in Kenya have undiagnosed alcohol abuse problems ( Ndetei et al., 2009). Rural areas in developing nations, as in economically established countries ( Roberts, 2007), are especially affected by mental health disparities.

Many developing nations have no policies to address the basic needs and rights of individuals with mental illness, which contributes to limited prioritization of mental health in health planning, resource allocation, and workforce development, further increasing unmet mental health needs. Research shows that in developing nations patients often leave hospitals without knowing their diagnosis or what medications they are taking ( Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993; Ndetei, Mutiso, Khasakhala, & Kokonya, 2007b), wait too long for referrals, appointments, and treatment ( Murray & Tantau, 1998) and are not respected or given adequate emotional support ( Botelho, Lue, & Fiscella, 1996; Sobel, 1995). In many communities, the burden of caring for the sick is placed on women and increasingly children because of the high adult morbidity and mortality due to HIV/AIDS and other infectious diseases. This has resulted in age and gender inequities in primary caregiver's responsibilities for people living with mental illness. Moreover, increased international migration of health workers from developing to the developed nations ( Connell, Zurn, Stilwell, Awases, & Braichet, 2007; Kirigia, Gbary, Muthuri, Nyoni, & Seddoh, 2006; Stilwell et al., 2003; Stilwell et al., 2004) and internal migration from rural poorer communities to more wealthier urban communities in the developing nations has further worsened the shortage of mental healthcare workers ( Mwaniki & Dulo, 2008; Ndetei, Khasakhala, & Omolo, 2008; Ndetei et al., 2007b). As a result, the majority of people with mental illness in developing nations go untreated despite the availability of effective treatment. These large treatment gaps are not surprising given that in many developing countries there is no budget for mental health services. Not only are mental health services scarce, but individuals who have mental disorders attending public medical services are required to meet the cost of their treatment (psycho-active drugs), while treatment for physical health problems is freely provided ( Ndetei, Khasakhala, Kingori, Oginga, & Raja, 2007a; WHO, 2005b). This disproportionately affects poorer people who are at greater risk of having mental disorders.

Stigma and discrimination

The burden of mental disorders in developing countries is compounded by high rates of stigma and discrimination, which are major obstacles in the provision and utilization of mental health services ( Horwitz, Roberts, & Warner, 2008; Okasha, 2002; Onyut et al., 2009; Ssebunnya, Kigozi, Lund, Kizza, & Okello, 2009). Research documents increasing social distance and stigmatization of people living with mental disorders in sub-Saharan Africa ( Adewuya & Makanjuola, 2005, 2008) even among mental health providers ( Ndetei et al., 2009). The stigma, myths and misconceptions surrounding mental illness contribute to much of the discrimination and human rights violations experienced by people with mental disorders ( Ndetei et al., 2007a). The laws, practices and social norms in many nations give extensive powers to guardians of people with mental disorders to decide where they live, their movements, their personal and financial affairs, and their care including their commitment to mental hospitals ( Ndetei et al., 2007a). Research, however, shows that clinicians and others, including family members, inaccurately judge what patients value ( Gerhart, Koziao-McLain, Lowenstein, & Whiteneck, 1994; Laine et al., 1996; Roberts et al., 2003; Roberts, Warner, Anderson, Smithpeter, & Rogers, 2004a; Roberts, Green Hammond, Warner, & Lewis, 2004b), resulting in unnecessary restrictions in the rights to work, education, marriage and participation in community or family functions.

Stigma associated with mental disorders can also influence career choices resulting in fewer people choosing to work in the mental healthcare field. Studies involving medical students in Colombia ( n = 375) ( Pailhez, Bulbena, López, & Balon, 2010), Saudi Arabia ( n = 54) ( El-Gilany, Amr, & Iqbal, 2010), and Spain ( n = 207) ( Pailhez et al., 2010), and medical residents in Romania ( n = 112) ( Voinescu, Szentagotai, & Coogan, 2010), published in a special collection recently demonstrated the negative attitudes that exist towards the medical specialism of psychiatry. For example, 82% of the Saudi Arabian students and 52% of the Romanian students in these survey projects endorsed the statement that 'if a student expresses interest in psychiatry, he or she risks being ... seen by others as odd, peculiar, or neurotic'. Large proportions of students had been actively discouraged by their medical school teachers, family members, friends, and fellow students from going into psychiatry ( El-Gilany, Amr, & Iqbal, 2010; Voinescu, Szentagotai, & Coogan, 2010).

Limited knowledge of the causes, symptoms and treatment of mental illness often leads to common but erroneous beliefs that these conditions are caused by individuals themselves or by supernatural forces, possession by evil spirits, curse or punishment following the individual's family or is part of family lineage ( Mohit, 2001). Disturbingly, physicians in training in some developing or economically disadvantaged countries hold these same beliefs, even after undergoing psychiatric training ( Roberts, 2010). For example, 23-40% of Nigerian medical students in one study endorsed supernatural causes of mental illness, such as charms, evil spirits, and witchcraft ( Aghukwa, 2010). These beliefs increase stigma, discrimination, and social isolation of individuals living with mental illness and limits resources for their care. Without effective diagnosis and treatment options, mental disorders are seen as untreatable, resulting in patients being undervalued and perceived as not able to contribute to society. In developing nations and in some communities in developed nations, the limited availability of modern mental health services and providers is offset by reliance on traditional and faith healers ( Beals et al., 2005; Hewson, 1998; Ngoma, Prince, & Mann, 2003; Ovuga, Boardman, & Oluka, 1999; Sorsdahl et al., 2009). Although these alternative healers play a critical role, they often lack the necessary training and skills to provide effective care for people with serious mental illness.

Mental disorders and economic development

The economic burden of mental disorder is great. In the USA the indirect costs associated with these disorders is estimated to be over $79 billion, with about $63 billion reflecting the loss of productivity because of illnesses ( Manderscheid, Druss, & Freeman, 2007). In Canada, the economic burden of mental illness in 2003 was about $34 billion ($1,056 per capita), with depression and schizophrenia accounting for about $5 billion and $2.7 billion annually, respectively ( Patra et al., 2007). Mental health conditions cost between 3% and 4% of the gross national product in the European Union member countries ( Gabriel & Liimatainen, 2000; WHO, 2005c).

The effect of mental disorders extends beyond individual and family suffering to national economic development. Mental health well-being is strongly related to many economic development sectors (e.g. education, employment, law enforcement and incarceration) ( Gureje & Jenkins, 2007) and several Millennium Development Goals ( United Nations, 2000), (e.g. eradicating extreme poverty and hunger, reduce child mortality and improve maternal health) ( Gureje & Jenkins, 2007; Miranda & Patel, 2005; WHO, 2002). These conditions can influence economic growth through their effects on labour supply, earnings, participation and productivity ( Dewa & Lin, 2000; WHO, 2002). Depression, for instance, can negatively affect education, employment, and productivity ( Berndt et al., 1998; Kessler & Frank, 1997), but productivity gains after effective treatment exceed direct treatment costs ( Simon et al., 2001).

Economic loss associated with decreased labour force participation and institutionalization of people with mental disorders is great. In the USA, about 3% of men and 4.5% of women cannot work or engage in regular activities because of mental or emotional problems. Men with mental disorders earn 21% less than men without mental disorders ( Robins & Regier, 1991). In Kenya, the economic loss associated with institutionalization of mental and behavioural disorders is about $13 million ( Kirigia & Sambo, 2003), a large amount in a country where over half of the population live on less than a dollar per day and have no safe drinking water ( UNDP, 2000). Unmet mental health needs can create social problems (e.g. unemployment, substance abuse, poverty) that may increase crime and political instability. Sen observes 'there is plenty of evidence that unemployment has many far-reaching effects other than loss of income, including psychological harm, loss of work motivation, skill and self-confidence, increase in ailments and morbidity (and even mortality rates), disruption of family relations and social life, hardening of social exclusion and accentuation of racial tensions and gender asymmetries' ( Sen, 1999, p. 94). In many developing nations these social problems are further compounded by poor governance, corruption and social morbidity due to natural and manmade disasters (e.g. wars) which increase mental health problems, erode social cohesion and capital, and limit economic growth ( Dewa & Lin, 2000; Njenga, 2002; WHO, 2002).

Integrating mental health into primary health care services

The mismatch between the global burden of mental disorders and availability of mental health resources is alarming. According to WHO, there is less than one psychiatrist for every 100,000 people in much of south-east Asia, and less than one psychiatrist for every 1 million people in sub-Saharan Africa ( Jacob et al., 2007; WHO, 2005b). Nigeria, for example, has 100 psychiatrists for its population of 114 million ( Gureje & Lasebikan, 2006). Globally, only 2% of national budgets are devoted to mental health ( WHO, 2005b). About 70% of African and 50% of south-east Asian countries devoted less than 1% of their health budget on mental health ( Jacob et al., 2007).

Given the scarcity of mental health providers in developing nations, the few psychiatric hospitals that exist are often understaffed, crowded, and may not provide the quality of care needed. Most psychiatric hospitals are located in urban settings and away from family members, which further increases the social isolation and cost for families. In some countries, these hospitals are simply 'warehouses' where patients are kept from the rest of the society because of limited resources and capacity to manage effectively their conditions. In developed nations (e.g. USA), deinstitutionalization of people with mental illness results in many patients, mostly racial/ethnic minorities, being incarcerated because of limited access and availability of basic mental health services in the community.

One key strategy for addressing inequalities in mental health care is to ensure the integration of mental health with other primary care services. Ongoing efforts to implement and enhance primary care in developing countries ( Rohde et al., 2008; Tejada de Rivero, 2003; Walley et al., 2008) must include mental healthcare, as a critical component of overall population health and wellbeing. Chan and Van Weel observe that:

For too long, mental disorders have been largely overlooked as part of strengthening primary care. This is despite the fact that mental disorders are found in all countries, in women and men, at all stages of life, among the rich and poor, and in both rural and urban settings. It is also despite the fact that integrating mental health into primary care facilitates person-centred and holistic services, and as such, is central to the values and principles of the Alma Ata Declaration. ( WHO/WONCA, 2008, p. vii)

Reasons for integrating mental health into primary care include the enormous social and economic burden, the interwoven nature of physical and mental problems, and the significant treatment gaps of mental health problems ( WHO/WONCA, 2008). Moreover, since primary care for mental health problems is affordable and cost-effective, such integration would generate good outcomes; promote access to care, and respect for human rights ( WHO/WONCA, 2008).

Community mental health services can help reduce social stigma and discrimination by reducing the social isolation, neglect, and institutionalization of people living with mental health problems. Effective community management of mental disorders also helps people realize that people with mental illness can live productive lives, contribute to society, and be integrated with society.

Data and the global burden of mental health problems

Efforts to address mental health problems must also address the pervasive lack of reliable data within and across nations ( WHO, 2005a). Health systems in many developing nations do not routinely collect mental health data ( Ndetei et al., 2007b), which can limit the ability of nations to accurately determine the burden of these conditions and develop plans to address them. Data limitations put mental health needs on the backburner for most policy makers and make it difficult for governments and international agencies to devote more resources to address mental disorders. Strategies, such as adding reliable mental health measures to ongoing population surveys (e.g. The Demographic Health Survey) can significantly improve availability of data for advocacy, programme planning and policy formation in many countries.

In conclusion, health reform agendas in the developed and developing nations need to provide legal protection, services, and human rights to people living with mental disorders. These policies must protect people with mental disorders from abuse, neglect, and discrimination, and afford them the care they need. Justice requires that people with mental illness receive the same societal and legal protection given to other people with physical health conditions. Ethical and human rights challenges in caring for people living with mental illness and their families exist. These include: (1) justification to provide mental health services to communities when primary healthcare services are inaccessible, unavailable, and unaffordable and therefore unsustainable in rural and hard-to-reach areas; (2) lack of public awareness on mental health and limited knowledge about the causes of mental illness which have resulted in mental health being given low priority by the policy makers and health providers, (3) the vicious circle between mental ill-health and poverty, (4) the role played by stigma towards individuals who have mental illness and their families, and (5) inadequate developed mental health policies, resulting in limitations to bring about major reforms in the implementation of mental health policies and service delivery needed by mental health systems.

Although the idea of health without mental health sounds absurd, mental health is perhaps the most neglected aspect of health in developed and developing nations. Addressing mental disorders often appears to be an afterthought in health and social policy development, added to existing 'more important health issues' rather than a part of individual and population overall health and wellbeing. In defining health, the WHO clearly articulated the importance of mental health by including it with overall physical and social well-being. By putting it in between the state of 'physical' and 'social' well-being, this definition symbolically shows how mental health ties physical health and social wellbeing together. Neglect of mental health needs in health policies often translates to neglect in research, funding, services, and infrastructure (e.g. the development of competent mental health workforce) especially in poor and underserved communities ( WHO, 2001a, 2001b). Mental health is vital to our understanding of health and economic development and must be prioritized in health planning, resource allocation and fully integrated with other primary care services.

Footnotes

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Mental disorders, health inequalities and ethics: A global perspective

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The global burden of neuropsychiatry diseases and related mental health conditions is enormous, underappreciated and under resourced, particularly in the developing nations. The absence of adequate and quality mental health infrastructure and workforce is increasingly recognized.

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Campaign video advocating for taking care of mental health early on, started by Mental Health America

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Information on the federal and state role in mental health in America.

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The Federal Role in Mental Health

The federal government works in partnership with the states to address mental health. The federal role in mental health includes regulating systems and providers, protecting the rights of consumers, providing funding for services, and supporting research and innovation. As a major funding source for mental health services, the federal government establishes and enforces minimum standards that states can then expand upon.

Federal Legislation and Regulations. Federal laws create changes and provide oversight across the states. Legislation at this level may take a longer time but can have a massive impact once passed. Regulations are rules issues by federal agencies to help implement the laws. In terms of mental health, regulations cover a variety of topics and apply to a number of groups including schools, insurance companies, treatment providers, and employers. These rules clarify just how major pieces of legislation like the Americans with Disabilities Act (ADA), the Rehabilitation Act, the Mental Health Parity and Addiction Equity Act (MPHAEA), and the Affordable Care Act (ACA) should be implemented. The agencies also issue additional guidance when questions about compliance arise. The federal government invites individuals and groups to submit comments on regulations. You might see this or hear this referred to as a notice for proposed rulemaking. For more information about how you can be heard, check out www.regulations.gov.

Federal Protections. The federal government works to protect the rights of individuals with mental health disorders in a variety of settings, including the workplace, schools, and in treatment. It sets privacy standards, prohibits abuse, and fights discrimination to promote civil liberties and inclusion. It works to provide reasonable accommodations and supports to those who need them. Mental Health America's history is deeply rooted in protecting the rights of those with mental health disorders, and this focus continues to guide our work. To learn more from MHA about rights and protections, check out Rights of Persons with Mental Health and Substance Use Conditions, Community Inclusion after Olmstead, and Privacy Rights.

Federal Role in Funding Services. The federal government is a major funding stream for mental health services. In addition to funding mental health services that fall under Medicare and the Department of Veterans Affairs (VA), it matches state Medicaid and CHIP (Children's Health Insurance Program) spending from between 50 to 70 percent, depending on the state. While these programs do not focus exclusively on mental health, Medicaid is the single largest funder of mental health services in the country, which makes this support especially valuable. The federal government also provides Mental Health Block Grants (MHBG) that support states in building out their community mental health services. MHA supports the continued role of the federal government in funding services and advocates for expanded and sustained funding for mental health services.

Federal Role in Research. Federal funding of mental health research creates opportunities to study causes of, treatments for, and recovery from mental health disorders that might not otherwise be available. Government agencies, like the National Institute of Mental Health (NIMH) or the Substance Abuse and Mental Health Services Administration (SAMHSA), lead research, administer grants, and educate the public about findings. This information contributes to our overall understanding of mental health disorders and services and can improve treatment and future research.

The States' Role in Mental Health

States have significant power in making decisions about their mental health systems so mental health regulations and available services can look very different from state to state and even from county to county. State mental health systems must meet certain standards set by the federal government, but they are free to expand beyond what exists at the federal level and improve services, access, and protections for consumers. This freedom to experiment with new or innovative services and delivery models allows states to create improvements that can ultimately be translated across the country.

State Legislation and Regulations. State laws create changes and provide oversight within the state. Regulations are rules issued by state agencies to help carry out laws. In terms of mental health, state regulations can address a variety of issues including treatment facilities, medical records, and standards for involuntary treatment. These rules help states to implement their mental health plans and provide guidance as to what is and is not allowed under law.

State Protections. States follow the protections established by the federal government with many states increasing protections even further. From the workplace to schools to treatment facilities, states have the power to increase standards for protecting privacy, fighting abuse, and eliminating barriers and discrimination to promote civil liberties and inclusion. This ranges from discretion over civil commitment standards to determining duty-to-warn laws to supporting access to the least restrictive services that keep people in the community. Mental Health America's history is deeply rooted in protecting the rights of those with mental health disorders, and this focus continues to guide our work. To learn more from MHA about rights and protections, check out Rights of Persons with Mental Health and Substance Use Conditions, Community Inclusion after Olmstead, and Privacy Rights.

States' Roles in Funding Services. A state's role in funding mental health services varies greatly across the U.S. While all states receive federal support via Mental Health Block Grants and partial funding of services provided through Medicaid and CHIP (Children's Health Insurance Program), each has freedom in designing and funding its mental health system. In addition to funding state hospitals, state funding is typically funneled to county and local levels where services are offered. Depending on the state's political and economic climate, states will play a more or less substantial role in funding comprehensive mental health services.

States' Roles in Research. Because they vary in their services and delivery of services, state reporting of outcomes provides important insight into what may or may not work and can translate into improvements both within a state and across other states. States often use models or areas that have been successful and filter programs upwards, expanding them in size or to other regions. This flexibility can create examples of new or improved programs that can then be implemented around the country. State funded academic institutions also play an important role in fostering research.

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The Federal and State Role in Mental Health

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The Federal Role in Mental Health The federal government works in partnership with the states to address mental health. The federal role in mental health includes regulating systems and providers, protecting the rights of consumers, providing funding for services, and supporting research and innovation.

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How Obamacare (The Affordable Care Act) helped and will continue to help Americans to get mental health coverage.

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Before the Affordable Care Act was enacted, mental health coverage was often lacking from health plans sold in the individual market. One in five American adults will experience a mental health issue at some point, but historically, millions have not gotten the care they needed due to the challenges of the health insurance market.

And in recent years, the opioid epidemic has cast a spotlight on the need for substance abuse treatment, which falls under the umbrella of mental/behavioral health care. Medicaid expansion - a cornerstone of the ACA - has dramatically expanded access to addiction treatment in some of the states that have been hardest-hit by the opioid epidemic.

Huge challenges of covering mental health

In 2013, a person with a bipolar diagnosis was unable to obtain private individual health insurance in most states. The same was true for people with schizophrenia and other psychotic disorders, anorexia, alcoholism, and a variety of other serious mental or behavioral illnesses.

Even for people with relatively minor mental health diagnoses, health plans were allowed to increase premiums during the initial underwriting process.

The underwriting rules that applied to mental health treatment often trapped people in the health plan they had when they were diagnosed, with no realistic opportunity to shop around when annual rate increases were announced. And for people who were uninsured at the time of their diagnosis, securing coverage was challenging and expensive - or impossible, depending on where they lived.

For those who had insurance, it often didn't cover mental health care. According to a 2013 analysis conducted by HealthPocket, only 54 percent of individual health plans in the United State included coverage for substance abuse treatment, and 61 percent covered mental health treatment. (Coverage was better among employer-sponsored plans.)

Parity laws - a good first step

In 1996, and again in 2008, Congress passed mental health parity laws, requiring large-group plans that cover mental health treatment to do so with benefits that are no less favorable than the benefits provided for medical/surgical care. The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) incorporated coverage for addiction treatment as well as general mental health care.

But the mental health parity laws don't require large-group plans to cover mental health and addiction treatment. They only require the plans to provide parity if such coverage is provided. And parity laws didn't apply to plans sold in the individual and small group markets.

The Affordable Care Act filled in the gaps

The Affordable Care Act was a turning point in terms of access to behavioral health coverage. The ACA eliminated medical underwriting in the individual and small group markets starting in 2014, so medical history - including mental health history -no longer results in enrollment denials or higher premiums.

And under the ACA, all individual and small-group plans with effective dates of January 2014 or later are required to cover ten essential health benefits with no annual or lifetime dollar limits. Mental health and addiction treatment (collectively referred to as behavioral health services) are among the essential health benefits.

The ACA also extended MHPAEA to include individual and small group plans, as well as Medicaid, in addition to the large group plans to which it originally applied. Since 2014, all new individual and small-group plans have covered mental health and addiction treatment, and have been required to do so with benefits that are no less favorable than benefits for medical/surgical care.

Large-group plans are not required to cover the ACA's essential health benefits (although if they do, they must do so without annual or lifetime dollar limits), but they are governed by MHPAEA. So if they provide coverage for mental health and addiction treatment, they must do so with parity to medical/surgical benefits. Shel Gross, Director of Public Policy for Mental Health America of Wisconsin, notes that large-group plans already tended to provide relatively generous benefits for mental health and addiction treatment prior to the ACA, and that's still largely the case today (large group plans, in general, tended to provide more generous benefits across the board; this is why the ACA's essential health benefits requirements were written to apply to the individual and small group markets).

Prescription drugs are also an essential health benefit under the ACA. According to HealthPocket's analysis, 18 percent of individual market health plans didn't cover prescription drugs in 2013. Thanks to the ACA, all new individual and small-group plans cover prescriptions, including medications to treat behavioral health problems.

Gross noted that there are still access problems stemming from the fact that carriers can - and do - restrict their formularies (covered drug lists), despite the fact that mental health drugs appear to work differently for different individuals. But compared with pre-2014 when health plans could opt to not cover medications at all - or to only cover generic drugs - the ACA has made prescriptions much more accessible.

Preventive care includes behavioral health screening

The ACA also requires all non-grandfathered health plans - including large-group plans - to cover a range of preventive care at no cost to the patient. Among the benefits included are depression and alcohol misuse screening for adults and adolescents, as well as autism screening and behavioral assessments for children.

Young adults get insured

In 2010, the ACA began allowing young adults to remain on their parents' health plans until age 26. This provision - along with the expansion of Medicaid and premium subsidies in the health insurance exchanges - has resulted in a sharp decline in the number of young adults without health insurance. According to US Census data, 22.1 percent of people aged 19-25 were uninsured in 2013, and that had fallen to 13.1 percent by 2016.

Johanna Jarcho, Ph.D, is a postdoctoral fellow at the National Institute of Mental Health. She explains that "the vast majority of mental health disorders do emerge during one's adolescence or early 20s." With the drop in the uninsured rate for young adults, treatment for mental health and addiction problems is much more within reach for this demographic than it was prior to the ACA.

But it's not just young adults who have gained health insurance as a result of the ACA. From 2010 to 2016, the number of Americans without health insurance fell by 20 million people. A 2013 University of Minnesota study found that people with mental health problems are disproportionately represented among the uninsured. The ACA's success in decreasing the uninsured rate means that a significant number of previously uninsured people with mental health problems have been able to obtain health insurance that covers mental health care.

Unfortunately, the uninsured rate has been creeping back up under the Trump Administration, and some of the ACA's coverage gains had been eroded by 2018.

Medicaid expansion

It's no secret that poverty and addiction are correlated. And World Health Organization data indicate that the prevalence of common mental illnesses among the poor is about twice as high as among the rich.

The prevalence of behavioral health problems among low-income Americans highlights the importance of the ACA's Medicaid expansion in making treatment available to this demographic.

Even before the ACA expanded Medicaid to millions of low-income, non-disabled Americans, Medicaid was covering more behavioral health treatment in the U.S. than any other payer. And from late 2013 to early 2018, total Medicaid and CHIP enrollment had grown by more than 17 million people, increasing Medicaid's reach in covering mental health care in the US.

An estimated 1.2 million people with substance use disorders have gained health coverage as a result of Medicaid expansion under the ACA. This is beneficial not only to the patients, but also to the hospitals and health care providers who care for people with serious mental health issues. A Commonwealth Fund analysis found that in states where Medicaid has been expanded, 13.4 percent of opioid-related hospitalizations were for uninsured patients in 2013, and that had fallen to just 2.9 percent by 2015. In states that hadn't expanded Medicaid, the drop was only from 17.3 percent to 16.4 percent in that same time frame.

By 2020, up to 32 million people will have gained access for the first time to mental health and addiction treatment coverage as a result of Medicaid expansion. And according to a 2015 Kaiser Family Foundation analysis, Medicaid benefits for behavioral health services tend to be more comprehensive than the benefits provided by private plans available in the ACA exchanges.

But 19 states still haven't expanded Medicaid, and there are more than 2.2 million low-income adults - many of whom suffer from behavioral health problems - in those states who have no realistic access to health insurance without Medicaid expansion (note that Maine and Virginia are not listed among the states where there are people in the Medicaid coverage gap, but low-income residents in both states are not yet covered by Medicaid expansion; in Maine, voters approved expansion in 2017, but the governor has been blocking implementation. And in Virginia, Medicaid expansion will take effect in 2019).

A 2014 report by the American Mental Health Counselors Association shows how pervasive mental health problems are among people with household income under 138 percent of the poverty level, and highlights the importance of ongoing legislative and advocacy work to expand Medicaid in every state.

Still work to be done

The ACA has dramatically increased coverage for behavioral health treatment. But the National Alliance on Mental Illness published a report in 2015 detailing problems with access to behavioral health providers, and limited coverage for some brand-name drugs, particularly anti-psychotics. The report also noted that health insurance companies were still more than twice as likely to deny authorization for mental health care, compared with authorization for general medical care.

Although insurance coverage - with behavioral health benefits - is much more widespread than it used to be, access to care is still limited in some circumstances. In many states, there's a shortage of mental health providers, which is magnified in rural areas. Shel Gross noted that two- to three-month wait times are not uncommon when new patients are seeking an appointment with a psychiatrist.

A Milliman study found that mental health care is much more likely than other medical care to be provided out-of-network, and insurers tend to reimburse mental health providers less than they reimburse primary care providers. Largely as a result of what the providers see as low reimbursement rates, nearly half of private psychiatrists in the US don't accept any health insurance at all - they're out-of-network no matter what insurance the patient has.

The mental illness with the highest mortality rate is anorexia nervosa. And yet patients continue to face insurance-related barriers that prevent them from receiving residential treatment for anorexia.

Clearly, there is still work to be done. But without the ACA, we'd still have 45 million people without health insurance, including a significant number of people with behavioral health problems. And health plans would still be able to deny applications based on medical history, and sell plans that didn't cover behavioral health treatment at all.

There are concerns, however, that some of these gains will be lost under the Trump Administration. Mental health advocates have noted that the proposal to expand access to short-term health insurance plans would result in more people buying plans that don't include mental health coverage, which consumers sometimes don't realize until they need mental health or substance use treatment. Similar concerns have been expressed about the Trump Administration's decision to expand access to association health plans.

Short-term plans and association health plans will attract healthier people, leaving a sicker risk pool in the ACA-compliant market. That will drive up premiums, resulting in unaffordable coverage for some enrollees who don't qualify for premium subsidies. That increases the uninsured rate, and results in more people with no coverage at all - for mental health care or anything else.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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How Obamacare improved mental health coverage

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Without the ACA, we'd still have 45 million people without health insurance, including a significant number of people with behavioral health problems. And health plans would still be able to deny applications based on medical history, and sell plans that didn't cover behavioral health treatment at all.

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A video about both a mother and son struggling to receive different types of therapy treatments despite having insurance in the US.

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Why insured Americans struggle to get mental health care

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NHS Long-Term Plan (10 year plan) includes major implications in mental health

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https://www.england.nhs.uk/mental-health/adults/

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One in four adults experiences at least one diagnosable mental health problem in any given year. People in all walks of life can be affected and at any point in their lives. Mental health problems represent the largest single cause of disability in the UK.

The NHS is placing more national focus than ever before on mental health. NHS England aims to deliver a transformation in mental health services by 2020/21, with an ambition of putting mental health on an equal footing to physical health in the NHS.

NHS England is making progress towards achieving the recommendations set out in the Five Year Forward View for Mental Health, involving the development and implementation of new models of care for adults with mental health needs.

Our key commitments include:

Developing pathways for mental health: as set out inImplementing the Five Year Forward View For Mental Health, to improve timely access to services delivered in line with NICE recommendations. A comprehensive set of pathways will be introduced over the next five years. The first to have been published, are:

Perinatal mental health:NHS England is transforming services so that more women experiencing mental ill health during or after pregnancy have access to the right care. This five-year transformation programme is backed by £365m extra investment.

Community-based adult mental health services:working with partners to improve access to high-quality, evidence-based care which considers people's physical and mental health needs and wellbeing, reducing premature mortality among people with severe mental illness and doubling the reach of Individual Placement and Support (IPS).

Urgent and emergency mental health care: as a signatory to theCrisis Care Concordat, NHS England began a major programme on crisis care, with the aim of ensuring 24/7 access to the right services for people experiencing mental health crisis. This includes £249m investment in urgent and emergency mental health liaison in acute hospitals, and investment in community crisis response (see below).

Acute mental health care:NHS England is aiming to improve the commissioning and provision of acute care for adults. This includes £400m investment in Crisis Resolution and Home Treatment Teams so that they are able to offer an alternative to inpatient hospital care, and to support our headline ambition to eliminate the practice of sending people long distances for non-specialist acute care by 2020/21.

Improving Access to Psychological Therapies (IAPT):This programme, which began in 2008, has transformed the treatment of adult common mental health disorders in England. NHS England is expanding it further:

To increase access by 2020/21 so that at least 25 per cent of people with common mental health conditions access services each year and to sustain and improve the quality of care, including recovery rates. A focus will be on co-locating services within primary and community health care so that treatment can be more convenient, timely and consider both their physical and mental health needs.

To increase access to psychological therapies for people with psychosis, bipolar disorder, and personality disorder.

Secure care: to improve pathways in and out of secure care, with a focus on developing community-based services to ensure people with severe mental health problems are cared for in the least restrictive setting, as close to home as possible.

Highlights

Individual Placement and Support webinars

We are running webinars to take a look at the IPS model and the benefits to people with serious mental illness. These events will update on investment being made to increase provision of IPS. . They are for commissioners and providers of secondary mental health services, local authorities, third sector providers, and IPS specialists. Register today:

Disruptive and Collaborative Innovations from the Academic Health Science Networks

This collection of case studies from the AHSNs focuses on innovative collaborations in mental health - highly relevant reading in relation to the Five Year Forward View for Mental Health.

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One in four adults experiences at least one diagnosable mental health problem in any given year. People in all walks of life can be affected and at any point in their lives. Mental health problems represent the largest single cause of disability in the UK.

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Mental Health Act - NHS

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In most cases when people are treated in hospital or another mental health facility, they have agreed or volunteered to be there. They may be referred to as a voluntary patient.

But there are cases when a person can be detained, also known as sectioned, under the Mental Health Act (1983) and treated without their agreement.

The Mental Health Act (1983) is the main piece of legislation that covers the assessment, treatment and rights of people with a mental health disorder. You can read the Mental Health Act on the government legislation website.

People detained under the Mental Health Act need urgent treatment for a mental health disorder and are at risk of harm to themselves or others.
Find out where to get urgent help for mental health

Advice for carers and families

If your loved one has been detained, they will have to stay in hospital until the doctors or a mental health tribunal decide otherwise.

You still have the right to visit. Visiting arrangements depend on the hospital, so check visiting hours with staff or on the hospital website.

In some cases the patient may refuse visitors, and hospital staff will respect the patient's wishes. If you're unable to see your loved one, staff should explain why.

With permission from your loved one, doctors may discuss the treatment plan with you.

You can also raise concerns or worries with the doctors and nurses on the ward.

Hospital accommodation should be age and gender-appropriate.

Not all hospitals will be able to offer a ward dedicated to each gender, but all should at least offer same-sex toilets and washing facilities.

For more information:

Who decides that someone should be detained?

In emergencies

An emergency is when someone seems to be at serious risk of harming themselves or others.

Police have powers to enter your home, if need be by force, under a Section 135 warrant.

You may then be taken to a place of safety for an assessment by an approved mental health professional and a doctor.

You can be kept there until the assessment is completed, for up to 24 hours. This can be extended to 36 hours, if it wasn't possible to assess you in that time.
Find out more about the Section 135 warrant on the GOV.UK website
If the police find you in a public place and you appear to have a mental health disorder and are in need of immediate care or control, they can take you to a place of safety (usually a hospital or sometimes the police station) and detain you there under Section 136.

You'll then be assessed by an approved mental health professional and a doctor.

You can be kept there until the assessment is completed, for up to 24 hours. This can be extended to 36 hours, if it wasn't possible to assess you in that time.
Find out more about the Section 136 warrant on the GOV.UK website
If you're already in hospital, certain nurses can stop you leaving under Section 5(4) until the doctor in charge of your care or treatment, or their nominated deputy, can make a decision about whether to detain you there under Section 5(2).

Section 5(4) gives nurses the ability to detain someone in hospital for up to 6 hours.

Section 5(2) gives doctors the ability to detain someone in hospital for up to 72 hours, during which time you should receive an assessment that decides if further detention under the Mental Health Act is necessary.
Find out more about Section 5 of the Mental Health Act on the government legislation website
Non-emergencies

In most non-emergency cases, family members, a GP, carer or other professionals may voice concerns about your mental health.

They should discuss this with you, and together you should make a decision about what help you may need, such as making an appointment with your GP to discuss further options.
Find out more about accessing NHS mental health services
But there may be times when there are sufficient concerns about your mental health and your ability to make use of the help offered.

In these circumstances your relatives or the professionals involved in your care can ask for a formal assessment of your mental health through the Mental Health Act process.

Your nearest relative has the right to ask the local approved mental health professional service, which may be run by local social care services, for an assessment under the Mental Health Act.

It's also possible for a court to consider using the Mental Health Act in some circumstances, or for a transfer to a hospital to take place from prison.

As part of this formal process, you'll be assessed by doctors and an approved mental health professional.

One of the doctors must be specially certified as having particular experience in the assessment or treatment of mental illness.
Find out more about getting a mental health assessment
The length of time you could be detained for depends on the type of mental health condition you have and your personal circumstances at the time.

You could be detained for:

up to 28 days under Section 2 of the Mental Health Act

up to 6 months under Section 3 of the Mental Health Act, with further renewals

During these periods, assessments will be regularly carried out by the doctor in charge of your care to determine whether it's safe for you to be discharged and what further treatment is required, if any.

You should always be given information about your rights under the Mental Health Act.
Find out more about your rights on the Care Quality Commission (CQC) website Read the Royal College of Psychiatrists' Q&A about being sectioned in England and Wales

What does the term 'being sectioned' mean?

The Mental Health Act is structured in many sections.

If someone says, "You're being sectioned under the Mental Health Act", they mean you're detained according to a particular section of the Mental Health Act.

In most cases, you'll be told which section of the Mental Health Act applied in your case. For example, "You're detained under Section 2 of the Mental Health Act".

How can I appeal against being detained?

Any person who's compulsorily detained has the right to appeal against the decision to the Mental Health Tribunal (MHT) or to the hospital's managers.

The MHT is an independent body that decides whether you should be discharged from hospital.

You may be eligible for legal aid to pay for a solicitor to help you do this.
Visit GOV.UK if you want to apply to the Mental Health Tribunal
You also have the right to see an independent mental health advocate if you're detained.

Ask the nurses on your ward or the hospital manager how you can get to see one.

An independent mental health advocate can help you understand your rights and could also help if you're not happy with your situation.

You can also make a complaint to the CQC if you're unhappy with the way the Mental Health Act has been used. Find out how to make a complaint on the CQC website.

Consent to treatment

If you're held under the Mental Health Act, you can be treated against your will.

This is because it's felt you do not have sufficient capacity to make an informed decision about your treatment at the time.

This is also the case if you refuse treatment but the team treating you believe you should have it.

The CQC provides detailed guidance about your rights in terms of consenting to medication and electroconvulsive therapy if you're detained in hospital or placed on a Community Treatment Order (CTO). Find out more on the CQC website:
CQC: Information for people detained in hospital CQC: Information for people subject to Community Treatment Orders (CTOs)

What is 'Section 17 leave'?

Going on leave from the hospital should form an important part of your care as you recover.

This means that while detained under the Mental Health Act, you may be able to leave the hospital if authorised by the doctor or clinician in charge of your care (also known as the responsible clinician).

This leave is often referred to as "section 17 leave", as it's Section 17 of the Mental Health Act that allows this leave.

The responsible clinician in charge of your care can place conditions on the leave, such as where you should stay while away from the hospital and whether this will be for a fixed period of time.

You should be given a copy of the Section 17 leave form that sets out these conditions so you're clear what they are.

The responsible clinician can revoke your leave and make you come back to hospital at any time.

If you do not return to the hospital at the end of the leave period, you can be made to go back to the hospital.
Find out more about Section 17 of the Mental Health Act on the government legislation website

What's a Community Treatment Order?

If you have been treated in hospital under the Mental Health Act and are being discharged or allowed out of the hospital on short-term leave, you may be put under a Community Treatment Order (CTO).

Under Section 17 of the Act, you can get leave but can be recalled to hospital if, for example, you stop taking required medication or your condition gets worse.

Make sure you know how long any leave is agreed for (usually 1 night or a weekend) before leaving the hospital.

You may be recalled to hospital during the leave if there are significant concerns about how you manage in the community.

If you're on leave or are being discharged, you may be made subject to a CTO if your doctor is concerned that you may not continue your treatment when you leave hospital.

Generally, a CTO means you can go home under certain conditions that you have to meet.

This is to protect yourself or others from harm and ensures you continue your treatment.

As normally occurs when someone is discharged from hospital, you'll be assigned a care co-ordinator, who'll help you with your mental health needs.

If you break the conditions of the CTO or your situation gets worse, you could be readmitted to hospital.

You could be detained for up to 72 hours while a decision is made about the next steps in your care.

Depending on your circumstances, your CTO could be revoked, which means you'll have to stay in hospital, or you could be allowed to leave hospital and continue your CTO.

While you're on a CTO, you can appeal against it. You may be eligible for legal aid to pay for a solicitor to help you do this.

You also have the right to see an independent mental health advocate and appeal to a mental health tribunal when you're on a CTO.

Ask your care co-ordinator, the nurses on your ward or hospital manager how you can get to see one.

An independent mental health advocate can help you understand your rights and could also help if you're not happy with any of your CTO conditions.
Find out more about your rights in relation to consent to medication and electroconvulsive therapy if you're subject to a CTO on the CQC website

What's the SOAD service?

The second opinion appointed doctor (SOAD) service safeguards the rights of patients subject to the Mental Health Act.

SOADs are consulted in certain circumstances when a patient refuses treatment, or is too ill or otherwise incapable of giving consent.

They'll check whether the recommended treatment is clinically appropriate and that your views and rights have been taken into account.

For example:

If you have already received medication for 3 months without consent under the Mental Health Act, the SOAD has to review whether continuous medication is really necessary.

If you're too ill to give valid consent to electroconvulsive therapy and your doctor feels it's necessary, the SOAD has to review whether it's appropriate for the treatment to be given. Electroconvulsive therapy cannot be given to a patient who's able to give consent but refuses to do so, except in urgent situations.

What's an approved mental health professional (AMHP)?

An approved mental health professional (AMHP) is a mental health worker who has received special training to provide help and give assistance to people who are being treated under the Mental Health Act.

Their functions can include helping to assess whether a person needs to be compulsorily detained (sectioned) as part of their treatment.

An AMHP is also responsible for ensuring that the human and civil rights of a person being detained are upheld and respected.

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In most cases when people are treated in hospital or another mental health facility, they have agreed or volunteered to be there. But there are cases when a person can be detained, also known as sectioned, under the Mental Health Act (1983) and treated without their agreement.

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Depression in adults: recognition and management | Guidance and guidelines | NICE

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Evidence-based recommendations on identifying and managing depression in adults aged 18 and over in primary and secondary care

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WHO

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Mental disorders affect one in four people

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The policy directions have never been so clear, says WHO. Governments who are just starting to address mental health will need to set priorities. Choices must be made among a large number of services and a wide range of prevention and promotion strategies.

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I've been seeing Lady Gaga's speech about mental health shared on social media a lot; goes with the movie A Star Is Born which also deals with mental health issues

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This might be Lady Gaga's best speech yet

Lady Gaga has never been one to shy away from talking about mental health. It's an incredibly important topic that carries so much stigma, and she's always been proud to be a star who will use her voice to normalize being open about it and encourage more people to seek help and mental health care.

Her acceptance speech at last night's Grammy Awards is no exception. After winning her third Grammy of the night for her smash song "Shallow" from A Star Is Born, Gaga used her time on stage to highlight the film's important messages about seeking help when you need it.

"I gotta thank God, thank you for looking out for me. Thank you for my family at home, I love you," Gaga began, visibly emotional onstage as she choked back tears.

Thank you to @ladygaga for speaking up about the need for better mental health care. We CAN do more to help our loved ones, and your voice sends courage to all who may be suffering. pic.twitter.com/D1PrpXkkGp

- Chirlane McCray (@NYCFirstLady) February 11, 2019

She then continued, "If I don't get another chance to say this: I just want to say I'm so proud to be a part of a movie that addresses mental health issues. They're so important. And a lot of artists deal with that and we got to take care of each other. So if you see somebody that's hurting don't look away. And if you're hurting, even if it might be hard, try to find that bravery within yourself to dive deep and go tell somebody and take them up in your head with you. I love you. Thank you so much to the Grammys."

Can we just pause for a minute here to talk about how she is, now and forever, an absolute queen? Ugh, Lady Gaga, from one girl who's struggled with some mental health problems, thank you for this.

And I'm far from the only person to appreciate her openness. Twitter absolutely lit up with others who had to speak out to thank Gaga for always being such a strong advocate and role model for those who are struggling with their mental health.

I really respect lady gaga so much and I'm so glad she's incredibly vocal about mental health. we really do need to emphasize how important asking for help is. it shouldn't be seen as weak to tell someone you need help.

- gabby ♡ (@gabby_frost) February 11, 2019

Lady Gaga likely just saved hundreds of lives from giving her message about mental health on the grand stage that she did. It's amazing how words lead to openness, which leads to hope for so many.

- Darren Rovell (@darrenrovell) February 11, 2019

Lady Gaga using her Grammys speech to talk about mental health and our need to take care of each other was another gift A Star Is Born has given us

- ilana kaplan (@lanikaps) February 11, 2019

Thank you for using every stage you have to talk about mental health, @ladygaga and congratulations on your message, your vision and ALL the awards. We love you! Love, Team @BTWFoundation

- Maya Enista Smith (@MEnista) February 11, 2019

What a kind soul @ladygaga She used her speech as an opportunity to talk about mental health and the importance of reaching out for help.#Grammy2019 #GrammyAwards #Grammys pic.twitter.com/k7bGYtSCD2

- Hazel Lou J. Pepania (@hazelloujaim) February 11, 2019

Powerful words on mental health tonight from @ladygaga: "If you see someone that's hurting, don't look away. And if you're hurting, even though it might be hard, try to find that bravery within yourself to dive deep and go tell somebody & take them up into your head with you." pic.twitter.com/fXw3eVqzUq

- Darren Rovell (@darrenrovell) February 11, 2019

Lady Gaga is right mental health is so important no matter who you love or hate we should all take care of each other if you see someone struggling even in your timeline please reach out and talk it's the least you could do #TearItUpBTS #GRAMMYs⁠ ⁠⁠⁠⁠ ⁠#BTSxGRAMMYs

- MANE🕊 (@CrystalSnowaye) February 11, 2019

I stan Lady Gaga for that #Grammys speech on mental health. So proud of this queen for winning 9 #GRAMMYs pic.twitter.com/mvmVhG8am9

- Bish, call me itta. (@planetofIttebaa) February 11, 2019

This isn't even the first time that Gaga has used her minutes on an awards show stage to preach the importance of taking care of yourself. During her acceptance speech at the SAG-AFTRA Patron of the Artists Award, she did the same. During that event, in November last year, she explained how the pressures of seeking jobs in Hollywood caused her to spiral into both mental and physical health problems. She's open about how she didn't seek help, but wishes she had.

"I'm telling you this because for me it was too late," she said at the time. "I needed help earlier. I needed mental health care. I needed someone to see not through me or see the star that I'd become but rather see the darkness inside that I was struggling with. I wish I had mental health resources then because although what I have is treatable and can hopefully and will get better over time, if there was preventative mental healthcare accessible to me earlier, I believe it might not have gotten as bad as it did. I wish there had been a system in place to protect and guide me. A system in place to empower me to say no to things I felt I had to do. A system in place to empower me to stay away from toxic working environments or working with people that were of seriously questionable character."

Lady Gaga, thank you again for using your time in the spotlight and your influence to speak about something as important as mental health. It's undoubtedly saving lives, and with an audience as large and diverse as all the people who watch the Grammys, someone's life may very well have been saved just last night.

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Stop Everything And Listen To Lady Gaga's Grammys Speech About Mental Health

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Lady Gaga has never been one to shy away from talking about mental health. It's an incredibly important topic that carries so much stigma, and she's always been proud to be a star who will use her voice to normalize being open about it and encourage more people to seek help and mental health care.

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Global Burden of Mental Disorders

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World Mental Health

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This World Health Day we look at what needs to be done to improve mental health around the world

Mental illness is a global problem. More than 300 million people, 4.4% of the world's population, suffer from depression. These alarming figures reflect the wider prevalence of mental ill-health more generally. It is estimated that mental health conditions will affect a staggering one in four people at some time in their lives.

Disparities abound, both between countries and particular groups. It is scandalous that 35-50% of people with severe mental health disorders in the Global North receive no treatment; but that figure roughly doubles to 76-85% for people living in the South.

The same disparity is seen in levels of civil society mobilisation (a vital element in any effective response). Organisations representing people with mental health problems and psychosocial disabilities are present in only 49% of low-income countries, compared with 83% of high-income countries.

Across the globe, particular groups, such as women, and people living in poverty, are disproportionately affected. So are refugees and asylum seekers, who are five times more likely to experience mental health issues than the general population. More than 61% of refugees will experience a mental health crisis or breakdown. This reflects another universal feature of mental illness: as with physical health, mental health is influenced by a wide range of social, political and economic factors. These include social and economic disadvantage and deprivation, low levels of education, unemployment or insecure employment, discrimination and violence.

Mental health in turn impacts on issues such as alcohol and substance misuse, abuse and gender-based violence. Failure to address mental health therefore has consequences for societies as a whole.

Much of all this - about the scale and the causes of the problem - has been known for some time. But the response to date, in terms of resources and political will, has been woefully inadequate. Despite the huge implications it has for global health, mental health receives a fraction of the funding of other diseases - both in allocations from Ministries of Health and development assistance.

And in terms of political prioritisation, the UK's recently-published plan for implementing the Sustainable Development Goals provides a telling insight. True enough, in the section on plans for Goal 3 ('Ensure healthy lives and promote well-being for all at all ages') in the UK; the paper does commit the Government to providing the necessary support and treatment for people suffering from mental ill-health. But when it comes to our commitments to the rest of the world, the document is silent on the issue of mental health.

Civil society organisations can also do more to develop and implement adequate responses to the global challenges of mental health. One example from Health Poverty Action's own experience was working with indigenous Mam communities in Guatemala to address violence against women. Working with local community leaders to address the lack of emotional and psychosocial support for survivors, we developed a course for local women leaders, traditional birth attendants and religious leaders.

It taught them to recognise depression and anxiety, and relate them to local cultural illnesses such as "soul loss". It also taught basic listening techniques, and use of locally available medicinal plants to help with relaxation and stress relief. As a result, women who suffer violent abuse are able to access a trained community counsellor to whom they can talk to in their own indigenous language, and find support to begin to rebuild their lives.

Mental health services must be incorporated as a core component of health systems and must be clear in calls for comprehensive primary health care.

Most fundamentally, any response to the global challenges of mental health will only succeed if it addresses the multiple social, political and economic determinants of the problem.

This World Health Day should provide the impetus for transforming how we understand, and respond to, the problem of mental illness, to give the issue the priority it needs and deserves.

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Mental illness is a global problem: we need a global response | Health Poverty Action

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This World Health Day we look at what needs to be done to improve mental health around the world Mental illness is a global problem. More than 300 million people, 4.4% of the world's population, suffer from depression. These alarming figures reflect the wider prevalence of mental ill-health more generally.

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Stress

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Abstract

Background: Mental health is a central determinant of quality of life. While psychiatric morbidity of populations has been studied extensively, the role of perceived stress, social support, and internal resources as determinant of health is still poorly understood. Methods: We surveyed 2000 randomly selected university students. Perceived stress was measured by the Brief Encounter Psychosocial Instrument, social support by the Duke-UNC Functional Social Support Questionnaire, internal resources (mastery and self-esteem) by a brief version of the Pearlin coping questionnaire. Linear regression models were used to explore the relationships between these variables and mental health, based on the SF-12 health survey. Results: After two reminders, 1257 students answered the questionnaire. In bivariate analysis, mental health was negatively associated with stress and positively associated with internal resources and social support (all p-values < 0.001). In multiple regression analysis, internal resources were positively associated with mental health, and buffered the negative impact of stress on mental health. Internal resources and stress mediated the positive impact of social support on mental health. Conclusions: Our data confirm that perceived stress is an important risk factor for low mental health and suggest that mastery and self-esteem are important protective factors of mental health among young adults.

Mastery Mental health Self-esteem Social support Stress Young adults

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Perceived stress, internal resources, and social support as determinants of mental health among young adults

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Background: Mental health is a central determinant of quality of life. While psychiatric morbidity of populations has been studied extensively, the role of perceived stress, social support, and internal resources as determinant of health is still poorly understood. Methods: We surveyed 2000 randomly selected university students.