Promoting Mental Health Internationally

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Promoting mental health internationally

Publication of this book was made possible by an unrestricted educational grant from Lundbeck.

Edited by GIOVANNI DE GIROLAMO, LEON EISENBERG, SIR DAVID P. GOLDBERG and JOHN E. COOPER

Promoting mental health internationally

Published in honour of Professor Norman Sartorius, to commemorate his many years of service with the World Health Organization

GASKELL

© The Royal College of Psychiatrists 1999 Gaskell is an imprint of the Royal College of Psychiatrists 17 Belgrave Square, London SW1X 8PG All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN 1-901242-37-4 Distributed in North America by American Psychiatric Press, Inc. ISBN 0-88048-970-7 The views presented in this book do not necessarily reflect those of the Royal College of Psychiatrists, and the publishers are not responsible for any error of omission or fact. Gaskell is a registered trademark of the Royal College of Psychiatrists. The Royal College of Psychiatrists is a registered charity (no. 228636).

Printed by Henry Ling Limited, Dorchester

Contents

List of contributors

vii

Introduction. A celebration of achievement L. Eisenberg, D. P. Goldberg, J. E. Cooper and G. de Girolamo

ix

Part I.

New concepts and methods in the mental health field

1

The foundations of the work of WHO in the mental health field L. Eisenberg, D. P. Goldberg, G. de Girolamo and J. E. Cooper

2

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Towards a common language for mental health workers J. E. Cooper

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Beyond ICD–10 and DSM–IV: issues in contemporary psychiatry A. Jablensky

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WHO’s contribution to mental health information transfer D. P. Goldberg

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Assessment instruments developed in the framework of WHO’s mental health programme A. Janca and C. Pull

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Part II. Contributions to knowledge 6 7 8

WHO’s contribution to the epidemiology of schizophrenia H. Häfner

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Biological research in psychiatry within the WHO programme on mental health J. Mendlewicz

103

The WHO neurosciences programme for the control of neurological disorders (1973–1986) C. L. Bolis

110

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Part III. Programmes and policies for specific disorders in the mental health field 9

10 11

WHO’s activities related to psychosocial aspects of health (including child and adolescent health and development) P. Graham and J. Orley

117

Mental disorders and health in the elderly A. S. Henderson

132

WHO programmes on prevention and control of drug and substance misuse M. Argandoña and M. Grant

138

Part IV. Regional and national mental health programmes 12

Development of regional and national mental health programmes N. N. Wig

13

The AMRO/WHO initiative to restructure psychiatric care in Latin America I. Levav and B. Saraceno 161

14

Documents produced by WHO on policies, guidelines and legislation for mental health and illness J. M. Bertolote 172

Part V.

A personal reminiscence

15

Experiences of a WHO consultant Index

R. Giel

153

179 185

Contributors

Mario Argandoña, Casilla de Coreo 2790, Crisostomo Carrillo 965, Cochabamba, Bolivia José M. Bertolote, Team Coordinator (Mental and Behavioural Disorders), Department of Mental Health, Social Change and Mental Health Cluster, World Health Organization, 1211 Geneva 27, Switzerland C. L. Bolis, Research Policy and Cooperation, World Health Organization, Avenue Appia, 1211 Geneva 27, Switzerland John E. Cooper, 25 Ireton Grove, Attenborough, Nottingham NG9 6BJ Giovanni de Girolamo, National Institute of Health, National Mental Health Programme, Viale Regina Elena 299, 00161 Rome, Italy Leon Eisenberg, Department of Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA Robert Giel, Professor of Social Psychiatry, Department of Social Psychiatry, University of Groningen, Postbox 30.001, 9700RB Groningen, The Netherlands Sir David P. Goldberg, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF Philip Graham, 27 St Albans Road, London NW5 1RG, UK Marcus Grant, International Centre for Alcohol Policies, 1519 New Hampshire Avenue NW, Washington, DC 20036, USA Heinz Häfner, Central Institute of Mental Health, PO Box 122120, D-68072 Mannheim, Germany Scott Henderson, NHMRC Psychiatric Epidemiology Research Centre, Australian National University, Canberra ACT 0200, Australia Assen Jablensky, Department of Psychiatry and Behavioural Science, MRF Building, 50 Murray St, Perth 6000, Western Australia Aleksandar Janca, Department of Psychiatry and Behavioural Science, MRF Building, 50 Murray St, Perth 6000, Western Australia Itzhak Levav, Programme Coordinator, Mental Health Programme, PanAmerican Health Organisation/World Health Organisation, 525 Twenty-third St NW, Washington, DC 20037, USA Julien Mendlewicz, Free University Clinics of Brussels, Hopital Erasme, Department of Psychiatry, Route de Lennik 808, 1070 Bruxelles, Belgium vii

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Contributors

John Orley, Chemin des Aranyes 270, 01220 Divonne-les-Bains, France Charles Pull, Service de Neuropsychiatrie, Centre Hospitalier de Luxembourg, 4 rue Barblé, Luxembourg 1210 Benedetto Saraceno, Director, Department of Mental Health, Social Change and Mental Health Cluster, World Health Organization, 1211 Geneva 27, Switzerland Narendra N. Wig, 279, Sector 6, Panchkula 134 109, Haryana, India

Introduction. A celebration of achievement

This book derives originally from an international meeting which was held in Geneva on 6 December 1993, on the occasion of the retirement of Dr Norman Sartorius. The meeting and the book share two main objectives: first, to honour the retirement of the man who had been at the forefront of the activities of the Division of Mental Health and its predecessors in WHO Geneva for more than 25 years, and second, to highlight the main achievements of the work of WHO in mental health activities over this period. Consequently this ‘Festschrift’ includes contributions both from people who have been or are currently WHO staff members and from distinguished colleagues who have collaborated closely with the Division’s programmes in a variety of roles over the course of the past 25–30 years. This book is not intended to be a complete description of all that has been achieved in this period; this would need a much larger work, and the subject matter is in any case available in the many publications that have appeared in the international press. But virtually all the programmes, projects and activities in which the work of WHO has been manifest since the 1960s are mentioned somewhere in these chapters, and between them the chapters give virtually all the relevant references for those who wish to study the details. In addition, despite the original function of a ‘Festschrift’, the analyses and the accounts included in the various chapters go beyond any narrow definition of the division’s remit of activities and deal directly with the most important topics related to international mental health. These contributions reflect the various priorities and the different levels of development that mental health has achieved in different parts of the world, and represent a coherent expression of the mosaic of problems that an international organisation has to face whenever it tries to tackle this impervious field in very uneven sociocultural settings, and in widely differing health systems and political structures. The four authors of this introductory chapter have long been closely involved in the work of WHO. One of us (LE) glows with the very ix

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special warmth which obstetricians feel when the infant whose birth they assisted attains healthy adulthood, because of his membership in a scientific group on mental health research, which met in Geneva in April 1964. Another of us (JEC) had the unusual pleasure of enrolling Dr Sartorius as a member of the US–UK Diagnostic Project in 1966 at the Institute of Psychiatry in London. He was one of the team of interviewers in the first study of hospital admissions in both London and New York, and so was one of the first group of psychiatrists to become experienced in the use of the Present State Interview (PSE), which was used subsequently in many WHO studies (Wing et al, 1974). Another of us (DPG) has collaborated with WHO in a variety of projects, particularly with respect to psychiatry in primary care. Finally, the youngest of us (G de G) had the privilege of working closely with Dr Sartorius in the WHO Division of Mental Health for a number of years before his retirement, and so was able to benefit directly from his enlightened guidance and suggestions. Only a brief biographical note is required for this volume. Originating from Yugoslavia, with degrees in both psychiatry and psychology, Dr Sartorius joined WHO in 1967, and almost immediately went on assignment to India. He moved to Geneva in 1969, became chief of the Office of Mental Health in 1974 and presided over its elevation to a Division in 1977. From the start, he showed himself to be a man of remarkable creativity and profound scholarship: the research output and publication record of the Division of Mental Health during his time would be the envy of most university departments. Some of the chapters of this book are largely technical in content, and some also contain personal comments, reminiscences and tributes. There are no simple or easy answers to the questions ‘What should be included, and who should be the authors?’. We can only offer the present contents as a mixture that seems to reflect appropriately enough the extraordinary variety and style of persons and activities that have to be encompassed by an organisation with world-wide responsibilities. At the time of writing, WHO Geneva is in the last stages of a major structural re-organisation, following the appointment of a new DirectorGeneral, Dr Gro Harlem Bruntland. Our good wishes go out to Dr Bruntland, Dr Saraceno and all those involved in the new era; they can rest assured that the outstanding reputation of WHO in mental health activities rests upon the firmest possible foundation. Leon Eisenberg Sir David P. Goldberg John E. Cooper Giovanni de Girolamo

Foundations of mental health work

Part I. New concepts and methods in the mental health field

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1

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The foundations of the work of WHO in the mental health field LEON EISENBERG, SIR DAVID P. GOLDBERG, GIOVANNI DE GIROLAMO and JOHN E. COOPER

The 1964 report of the Scientific Group on Mental Health Research began by acknowledging the extensive lacunae in the knowledge base of psychiatry. It was noted that the introduction of psychotropic drugs and the new emphasis on the community had produced marked changes in practice patterns, but the paucity of operational research on treatment effectiveness was stressed. The report then proposed priorities for mental health research at WHO. Those priorities make interesting reading 30 years later. It is worth noting what the members of the Scientific Group were able to see, what they failed to see, and what they over- and under-valued. Those priorities are listed in Table 1.1. In the mid-1960s, it required no Nostradamus to recognise that epidemiology must be the foundation for all WHO research. Five years earlier, Stengel (1959) had noted “almost general dissatisfaction with the state of psychiatric classification, national or international”. The problem with existing schemes, Stengel asserted, was that they were aetiological rather than phenomenological. An expert committee on the epidemiology of mental disorders, convened by WHO in 1959, had stressed the need for reliable and valid data on incidence and prevalence. Two monographs, one by Reid (1960) on epidemiological methods and one by Lin & Standley (1962) on the scope of epidemiology in psychiatry, had already been produced under the aegis of the Office of Mental Health. Thus, first priority was assigned to developing an internationally acceptable classification of mental disorders, a glossary of terms, 3

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and standardised procedures for case finding. Once this had been accomplished, field studies of defined populations were to be undertaken in order to ascertain psychiatric morbidity. The report called for studies of suicide, of changes in morbidity with time, and of the ‘natural history’ of the major mental illnesses. To make this possible, it was essential to train psychiatrists and others in research methods as well as to establish a research reference centre in Geneva. At the same time, operational research (defined as the study of patient samples and of medical interventions) was to be pursued in order that countries could begin to collect uniform data and establish cumulative case registers. Future undertakings were to include comparative studies of the outcome of different modes of service organisation. The second major rubric was entitled ‘cultural and environmental factors’. The diversity of cultures throughout the world, it was noted, constituted natural laboratories in which crucial variables affecting human behaviour range over a far wider spectrum and in a more vital fashion than could be achieved by planned experiment. Studies of the genetics of mental disorder were given third priority. It is possible to remain puzzled that the Scientific Group members agreed to assign so prominent a place to a topic more suited to national than international laboratories. Perhaps they were carried away by the recent discovery of the Down’s syndrome karyotype and by the promise in screening programmes for inherited metabolic disorders. Fourth priority was appropriately assigned to mental retardation; the group called for studies of prevalence, of service needs, of the effectiveness of educational methods and of specific medical treatments, work that John Orley was to coordinate so effectively (WHO, 1985). Priorities 5 and 6 were placed on studies of development and of geriatric psychiatry, both of which were and are of major public health importance. The seventh item was “the conditioned reflex approach and learning theory”. Eighth place was given to biological psychiatry; reasonable perhaps, but perversely enough, the Scientific Group highlighted laboratory research rather than clinical psychopharmacology: As far as WHO is able to put into effect its plans for the creation of its own research institute, the Scientific Group strongly recommends that serious consideration be given to including a department devoted to fundamental research in the field of mental health.

Fortunately, neither the institute nor the laboratory came into being, but perhaps Dr Sartorius had noted the wish of the group in what he went on to do. Priorities 9 and 10 were assigned to psychosomatic disorders and to psychotherapy; hard as it now is to believe,


5

TABLE 1.1 Research priority list of the 1964 Scientific Group on Mental Health 1. Epidemiology 2. Culture and Environment 3. Genetics 4. Mental Retardation 5. Development 6. Geriatric Psychiatry 7. Conditioned Reflex/Learning 8. Biological Psychiatry 9. Psychosomatic Disorders 10. Psychotherapy 11. Substance Abuse 12. Industrial Psychiatry 13. Forensic Psychiatry

alcohol and drug misuse did not appear until 11th on the list, just antecedent to industrial psychiatry; forensic psychiatry, listed last, was given short shrift. The text made no mention of the legal rights of the mentally ill nor of formulating model mental health legislation. In 1964, the ‘experts’ had not a word to say about psychiatry in primary care even though Michael Shepherd had begun his studies of general practice patients in 1958, and findings were already available in the literature (Kessel, 1960; Shepherd et al, 1966). Perhaps the Scientific Group members may be forgiven. The World Health Assembly was not to proclaim the goal of ‘Health for All By the Year 2000’ until 1977 (WHO, 1978a) and the International Conference on Primary Health Care in Alma Ata did not take place until the following year (WHO, 1978b).

Major achievements in the work of WHO We thought that it was appropriate to start this chapter with this brief historical account not only because the years of 1964 and 1965 marked the start of a 30-year close collaboration between two of us and WHO Geneva, but also to place the beginnings of the WHO mental health research programme in the intellectual currents of its time. Work on operational criteria for diagnosis was already under way. Sir Aubrey Lewis (1946), Michael Shepherd (1957) and Martin Roth (1959) had each noted striking differences between mental hospital admission rates by age and by diagnosis between the UK and the USA, with rates for schizophrenia lower and rates for depression higher in the UK than in the USA (Kramer, 1963). The USA/UK Diagnostic Project was to show that the apparent differences

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were almost entirely due to the differential prevalence of diagnostic practices, not of mental disorders (Zubin, 1969; Cooper et al, 1972). The successful use in this study of the PSE on a large scale was an important facilitator for the International Pilot Study of Schizophrenia (IPSS), starting about one year later. Within a year of the Scientific Group Report, the Office of Mental Health convened a seminar in London on ‘Standardisation of Psychiatric Diagnosis, Classification and Mental Health Statistics’. The participants noted three principal sources of disagreements among clinicians: “variations at the level of observation; ... variations ... in the inference drawn from such observations; and variation in the nosological schemata employed by the individual clinicians. These sources of variation are open to investigation” (Shepherd et al, 1968). Successive seminars proceeded systematically through the major categories of mental illness at yearly intervals for a decade. These seminars and the field trials associated with them led to a reformulation of the way mental disorders were classified in the eighth and ninth revisions of the International Classification of Diseases, culminating in the preparations for ICD–10. For this, the Division of Mental Health organised field trials in 40 countries, an unparalleled empirical research effort to validate psychiatric diagnosis (Sartorius et al, 1993a). The International Pilot Study of Schizophrenia (WHO, 1975) was initiated in 1966. The rich yield of this cross-national study included an unanticipated clinical finding at the two-year follow-up which defied conventional wisdom: there were substantial differences in patient outcome, but it was the patients in developing countries, for example Nigeria, India and Colombia, who did better than patients in the industrial countries, such as the USA, Czechoslovakia, UK and Denmark (WHO, 1979). Was this no more than a bizarre result of sampling flaws? That question was answered in the negative by the WHO tencountry ‘Determinants of the Outcome of Severe Mental Disorders’ study (Sartorius et al, 1986; Jablensky et al, 1992); study subjects were identified at the point of their first lifetime contact with any helping practitioner in their community. Although there were no differences between patients in rich and poor countries in recency of onset or in the frequency or severity of core symptoms, course and outcome once again differed markedly, with patients in the developing countries achieving and maintaining significantly longer periods of complete remission. As expected, those with acute onset had a much better prognosis than those with insidious onset, whatever their nationality. However, the fact that acute onset was more common in the developing countries did not account fully for the highly significant overall difference; the prognosis for cases with insidious onset was also better in the southern hemisphere.


7

Which elements in the contrasting cultural and material environments account for the robust clinical findings remains a puzzle; that socio-cultural determinants do have a significant impact on the course of schizophrenia is abundantly clear. We have thus far summarised two major WHO contributions to the field of psychiatry: an international classification scheme and the crosscultural study of the course and outcome of schizophrenia. But even more important than the empirical data and conceptual advances they produced, each led to even more enduring benefits, namely, intellectual cooperation across national boundaries and a series of national collaborating centres which provide a solid infrastructure for subsequent local training and research. In effect, the cross-national activities of the Division have left in their wake an ‘invisible college’ of colleagues who speak a common language, share a strong commitment to empirical research and are united in their regard for patient rights. The collaborative centres, in turn, strengthen indigenous research capacity and give visibility to local investigators, visibility which supports their request for country funds. How heartening is this contrast with the ‘parachute research’ of the past in which Western nationals took snapshots of exotic phenomena in poor countries and left naught but ashes from their campfires! The difference is not happenstance. The Division has codified the elements necessary for an effective collaboration between developing and industrialised nations: a jointly defined problem relevant to all participants; avoiding harm to the lowincome partner by assuring that country resources will not be diverted from more important endeavours; leaving enduring benefits in the form of trained personnel and sophisticated instruments translated into the local language; joint publication plans which value the contribution of each participant; specifying ethical standards for research subjects at the level of the country with the strictest regulation; and rules for access to data, authorship and publication spelled out before the study starts (Sartorius, 1988).

Primary care as the cornerstone for mental health care The third broad conceptual leap was to identify primary care as the principal venue for mental health training. WHO service in India and peripatetic visits to low-income countries made Dr Sartorius directly aware of the realities of clinical practice in Africa, Asia and Latin America. In consequence, the Division zeroed in on mental and behavioural problems in primary health care, the only care available in countries where resources are limited. Today, it takes no genius to recognise that fact. ‘Primary health care’ is recited like a mantra in

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every health policy statement. But the importance of mental health in primary care was far from obvious 25 years ago; many of our colleagues still haven’t got the message! We have already noted the failure of the 1964 Scientific Group Report even to mention general practice. Implicit in that report was the belief that training larger cadres of psychiatrists was the only way to supply mental health care in developing countries. Few understood that most of the care for mental and behavioural disorders, such as it is, in rich countries as well as poor ones, is provided by general practitioners or not provided at all (Regier et al, 1978, 1993). Agreed, there is a need for more psychiatrists; without specialists to educate primary health care workers, to back them up as consultants, and to undertake the care of the most seriously ill, the effectiveness of primary health care will be sharply limited. However, psychiatrists are neither likely to be available nor to be the best or the most cost-effective choice for providing front line care for the one-quarter to one-half of patients who bring psychosocial problems as their primary or secondary complaint to the health care system (Eisenberg, 1992). Are clinic attendees with psychological symptoms ‘real’ patients in need of care or are they the ‘worried well’, who should be discouraged from attending? Kenneth Wells and his colleagues (1989) compared the functional status of depressed patients seen in primary care practice with that of patients suffering from one of eight other chronic conditions: hypertension, diabetes mellitus, coronary artery disease, angina pectoris, arthritis, back problems, lung problems, and gastrointestinal disorders. On 17 of 24 pair-wise comparisons, the depressed patients were worse off than the medical patients. Only chronic heart disease produced more disability. Patients with chronic medical conditions and symptoms of depression were doubly disadvantaged. Yet half or more of these patients are not recognised by primary health providers and are not treated (Harding et al, 1980; Sartorius et al, 1990a; Eisenberg, 1992; Goldberg & Huxley, 1992; Sartorius et al, 1993b). When treatment is offered, too often it is homeopathic in its dosages of medication and counselling. To its everlasting credit, the Division took the lead on these matters more than two decades ago (WHO, 1972). It has designed training manuals, set forth a formulary of essential psychotropic drugs (including anticonvulsants for the treatment of epilepsy), initiated short courses for primary health care and developed a version of the ICD– 10 classification for use in primary care that includes specific treatment recommendations (WHO, 1990a, 1992). Moreover, the Division has completed an unparalleled study of mental illness in general health


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care (Sartorius et al, 1993c; Sartorius & Ustun, 1994), in which more than 25 000 medical out-patients have been assessed in 15 different countries including India, Nigeria, Chile, Brazil and China. Once again, the data document the substantial morbidity, the large amount of disability, and the low physician recognition rate for psychological disorders in primary health care. The yield from this study will benefit our field for a decade to come.

Health, mental health and society issues The fourth overriding theme in the Division’s work is that addressing the needs of the mentally ill requires going well beyond the health system. It remains a bitter fact that mental illness is severely stigmatised in most societies. Not only are the mentally ill denied equal access to health care even in countries as wealthy as the USA, but in many others they are denied the most elementary legal rights. In the summer of 1990, some 30 patients died from severe malnutrition in the Moyano Hospital in Buenos Aires, a state-run 1600 bed warehouse for mentally ill women; the diet at the hospital consisted of small portions of rice alternating with small portions of polenta (a cornmeal mush) in alternating weeks. More than state neglect was at stake. The tragedy could only have happened because the families of the patients were as indifferent to them as though they were already dead and because the patients had neither legal rights nor advocates to plead their cause (Christian, 1990). Similar public scandals have erupted in high income countries, as well. To combat this, the Division has designed model laws, encouraged non-governmental organisations to promote such laws, has educated national leaders on their importance and has analysed national mental health legislations in order to foster the adoption of similar principles and measures (Curran & Harding, 1978); this work has recently been replicated in as many as 50 countries.

Health prevention and promotion The fifth and final major theme running through the Division’s efforts is disease prevention and health promotion. The overriding goal is to increase public understanding that for each individual, good mental health is a pre-requisite for good overall quality of life. This is likely to be the most effective way of ensuring that public authorities will include mental health issues as vital components of their programmes for the improvement of family life, public education, general health care and conditions in the work place. How can the quality of mental life be

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enhanced? This is possible through such measures as: educating parents to understand that talking to, playing with and responding to infants stimulates cognitive and emotional development; school and community projects to increase the psychosocial competence of adolescents; training in conflict resolution to reduce impulsive resort to violence; legislation to require that the impact on mental health be taken into account when plans are set for economic development; projects to add purpose and dignity to the lives of the elderly after retirement. These few examples but hint at the spectrum of health promotion activities. At the same time, the Division has been a vigorous advocate for scientifically based methods to prevent mental, neurological and psychological disorders (WHO, 1986). The relevant document that one of us (LE) helped to prepare as a consultant to the Division was approved by the WHO Executive Board, with only minor changes, in the winter of 1986 (EB 77/1986/REC/2, pp. 138–144). In essence, it calls for: family planning to assure that infants are born wanted; medical, nutritional and social services to protect the health of those children; schools and community based psychosocial interventions to ensure optimal emotional and cognitive development; secondary prevention through early detection and prompt treatment of mental and behavioural problems in primary health care; and tertiary prevention through rehabilitation to minimise handicap. Community participation and intersectoral cooperation are highlighted as essential to programme success. That draft was presented to the World Health Assembly and adopted as Resolution WHA 39.25 in May of 1986. Although problems have been encountered in the implementation of this resolution, nonetheless, the basic principles of prevention had been widely accepted.

Conclusions The Division’s accomplishments could not have been the work of one man, no matter how gifted. During the tenure of Sir George Solti, it is said that the Chicago Symphony Orchestra became the best in the world. When the audience thrilled to Beethoven’s Ninth, it knew that Sir George was not also singing and playing the strings, woodwinds, brasses and tympani. For those roles, he had selected a legion of virtuosi. So it has been with Maestro Sartorius. He wields the baton and inspires his players, but the first desk men and women he chose have been virtuosi: Walter Gulbinat, Assen Jablensky, John Orley and Liana Bolis; John Henderson and Marcus Grant; Taha Baasher, Tim Harding and Narendra Wig; Inayat Kahn and Naotake Shinfuku; Felix Vartanyan and Helmut Sells; Leonid Prilipko, Peter Morosov and


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Alexander Janca; Joy Moser and Itzhak Levav; Renee Gonzalez and Awni Arif; Jose Bertolote and Bedirhan Ustun. From time to time, guest conductors, famous soloists, visiting singers, and even composers in residence were summoned from abroad to join the chamber orchestra. Were we to name them all, we would usurp the remainder of this volume. Let it be acknowledged; just as Sir George Solti was preceded by Frederick Stock, Fritz Reiner and Rafael Kubelik, our Maestro had his predecessors, such as Pieter Baan and Boris Lebedev (both notably supported by Tsung-yi Lin), and Ferdinand Hassler. Moreover, to give credit where credit is due, his ensemble needed patrons in the upper reaches of WHO to shield it from the Machiavellian intrigues that its very success aroused; Hafdan Mahler and Tomas Lambo, the DG and the DDG, were some of those patrons. Thank you, one and all, for making it possible for the Division to hold high the banner of international mental health.

References CHRISTIAN , S. (1990) Argentine deaths bring focus on healthcare. New York Times International Edition, 11 August, p. 5. COOPER , J. E., K ENDELL , J. E., G URLAND , B. J., et al (1972) Psychiatric Diagnosis in New York and London. Maudsley Monograph No. 20. London: Oxford University Press. CURRAN , W.J. & H ARDING , T.W. (1978) Law and Mental Health: Harmonizing Objectives. Geneva: World Health Organization. EISENBERG, L. (1992) Treating depression and anxiety in primary care: closing the gap between knowledge and practice. New England Journal of Medicine, 326, 1080–1084. GOLDBERG, D. & HUXLEY, P. (1992) Common Mental Disorders: A Biosocial Model. London: Routledge. HARDING , T. W., D EA RANGO , M. V. & B ALTAZAR , J. (1980) Mental disorders in primary care: a study of their frequency and diagnosis in four developing countries. Psychological Medicine, 10, 231–241. JABLENSKY, A., SARTORIUS, N., ERNBERG, G., et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten country study. Psychological Medicine, Monograph Supplement 20. Cambridge: Cambridge University Press. KESSEL, N. (1960) Psychiatric morbidity in a London general practice. British Journal of Preventive and Social Medicine, 14, 16–22. KRAMER , M. (1963) Some problems for international research suggested by observations on differences in first admission rates to the mental hospitals of England and Wales. In Proceedings of the Third World Congress of Psychiatry, Montreal, 1961. Vol. 3, p. 153. Toronto and Montreal: University of Toronto Press and McGill University Press. LEWIS , A. J. (1946) Aging and senility: a major problem in psychiatry. Journal of Mental Science, 92, 150–170. LIN , T.-Y. & S TANDLEY , C. C. (1962). The Scope of Epidemiology in Psychiatry. Public Health Papers No. 16. Geneva: World Health Organization. R EGIER , D. A., G OLDBERG , I. D. & T AUBE , C. A. (1978) The defacto U.S. mental health services system. Archives of General Psychiatry, 35, 685–693. ——, N ARROW , W. E., R AE , D. S., et al (1993) The de facto U.S. mental and addictive disorders system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85–94.

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R EID , D. D. (1960) Epidemiological Methods in the Study of Mental Disorders. Public Health Papers No. 2. Geneva: World Health Organization. ROTH , M. (1959) Mental health problems of aging and the aged. Bulletin of the WHO, 21, 527–561. S ARTORIUS , N. (1988) Experience from the Mental Health Programme of the World Health Organization. Acta Psychiatrica Scandinavica, 78 (Suppl.), 71–74. ——, J ABLENSKY , A., K ORTEN , A., et al (1986) Early manifestations and first-contact incidence of schizophrenia in different cultures. Psychological Medicine, 16, 909–982. ——, G OLDBERG , D., DE G IROLAMO , G., et al (1990a) Psychological Disorders in General Medical Settings. Bern: Hogrefe and Huber Publishers. ——, J ABLENSKY , A., R EGIER , D. A., et al (eds) (1990b) Sources and Traditions of Classification in Psychiatry. Bern: Hogrefe and Huber Publishers. ——, DE G IROLAMO , G., A NDREWS , G., et al (1993a) Treatment of Mental Disorders: A Review of Effectiveness. Washington, DC: American Psychiatric Press. ——, K ELBER , C. T., C OOPER , J. E., et al (1993b) Progress toward achieving a common language in psychiatry: results from the field trials of the clinical guidelines accompanying the WHO Classification of Mental and Behavioral Disorders in ICD– 10. Archives of General Psychiatry, 50, 115–124. ——, U STUN , T. B., C OSTA E S ILVA , J. A., et al (1993c) An international study of psychological problems in primary care. Archives of General Psychiatry, 50, 819–824. —— & U STUN , T. B. (eds) (1994) Mental Illness in General Health Care Across the World: An International Study. New York: John Wiley & Sons. SCIENTIFIC G ROUP ON M ENTAL H EALTH R ESEARCH (1964) Report to the Director General, 6–10 April. MHO/PA/75.64. Geneva: World Health Organization. SHEPHERD , M. (1957) A Study of the Major Psychoses in an English County. Maudsley Monograph No. 3. London: Chapman and Hall. ——, C OOPER , B., B ROWN , A. C., et al (1966) Psychiatric Illness in General Practice. London: Oxford University Press. ——, B ROOKE , E. M., C OOPER , J. E., et al (1968) An experimental approach to psychiatric diagnosis. Acta Psychiatrica Scandinavica, Suppl. 201. Copenhagen: Munksgaard. STENGEL , E. (1959) Classification of mental disorders. Bulletin of the World Health Organization, 21, 601–663. WELLS, K. B., STEWART, A., HAYS, R. D., et al (1989) The functioning and well being of depressed patients: results from the Medical Outcomes Study. Journal of the American Medical Association, 262, 914–919. WHO (1972) Group Meeting on Mental Health. Alexandria, 4–7 September. EM/MENT/49 EM/ GR.MT.MH/17 EMRO 5403. —— (1975) Schizophrenia: A Multinational Study. Public Health Papers No. 63. Geneva: World Health Organization. —— (1978a) Alma Ata 1978: Primary Health Care. Geneva, Health For All Series, No. 1. Geneva: World Health Organization. —— (1978b) Formulating Strategies for Health for All by the Year 2000. Health For All Series, No. 2. Geneva: World Health Organization —— (1979) Report of the International Follow-up Study of Schizophrenia. New York: John Wiley & Sons. —— (1985) Mental Retardation: Meeting the Challenge. WHO Offset Publication, No. 86. Geneva: World Health Organization. —— (1986) Prevention of Mental, Neurological and Psychosocial Disorders (Document WHO/ MNH/EVA/88). Geneva: World Health Organization. —— (1990a) The Introduction of a Mental Health Component into Primary Health Care. Geneva: World Health Organization. —— (1990b) Report of the Second Consultation on the Neuropsychiatric Aspects of HIV-1 Infection (Document WHO/GPS/MNH/90.1). Geneva: World Health Organization.


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—— (1992) Annotated Directory of Mental Health Training Manuals. Fourth edition (WHO/ MNH/MND/92.15). Geneva: World Health Organization. WING, J. K., COOPER, J. E. & SARTORIUS, N. (1974) The Measurement and Classification of Psychiatric Symptoms. Cambridge: Cambridge University Press. ZUBIN , J. (1969) Cross national study of diagnosis of the mental disorders. American Journal of Psychiatry, 125 (Suppl.), 12–20.

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Towards a common language for mental health workers JOHN E. COOPER

Introduction This chapter describes the main features of the development by the World Health Organization of three successive versions of the International Classification of Mental and Behavioural Disorders, in the context of a variety of other closely related activities. The recent publication of the ICD–10 Classification of Mental and Behavioural Disorders (full title: Chapter V [F] of the Tenth Revision of the International Classification of Diseases and Health Related Problems) is one of the most recent and obvious results of an extensive programme of activities that started more than 30 years ago. Together with a number of standardised interviewing and rating instruments, notably the Schedules for Clinical Assessment in Neuropsychology (SCAN; Wing et al, 1990; WHO, 1994a) the Composite International Diagnostic Interview (CIDI; Robins et al, 1988; WHO, 1993b) and the International Personality Disorder Examination (IPDE; Pull & Wittchen, 1991; WHO, 1992b; Loranger et al, 1994), the new classification is part of an extensive package or ‘family’ of closely related assessment procedures. (For comments on the latest versions and stage of development of all three instruments, see Janca et al, 1994, and Chapter 5.) The first part of this chapter outlines the stages of the complete programme, and the subsequent parts describe briefly the developments that have led up to the most recent version of the international psychiatric classification. This chapter therefore includes comments on the large-scale WHO collaborative studies on schizophrenia and related disorders, but these are limited to brief summaries or points of 14

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special importance (more about these studies can be found in Chapter 6). It will be seen that the present classification and related instruments are the culmination of many years of planning, which have actively involved hundreds of mental health professionals in many countries. A continuing network of centres and individuals carrying out long-term programmes of work have been the key features of this extraordinary effort. (It should be noted here that the sum of all the activities of the WHO in the field of mental health is considerably greater than what is contained in the two large programmes described in this chapter. A brief but more comprehensive account of the whole, ranging from the neurological and biological to the social and the legal, can be found in work by (Sartorius, 1989, 1992).) The activities to be described fall into three main phases. The first dates from about 1956 to 1964 and consists of preliminary activities and some important publications that set the scene for later activities. The second phase covers the four programmes, A, B, C and D (1965 to 1980; Lin, 1967), and the third, from around 1981 to the present, covers the activities of the WHO–ADAMHA Joint Project (Jablensky et al, 1983; WHO & ADAMHA, 1985). The purpose of this chapter is to give a commentary rather than a mere description of the programme of work, so some personal and historical notes have also been included.

The centre of the network: WHO in Geneva A large proportion of the mental health activities organised from WHO Geneva has always concerned issues of public health and epidemiology (Sartorius, 1993). This can be traced back to the tenure (1949–1955) of Professor Hargreaves, previously of the University of Leeds, UK, the first Chief of what was then the Mental Health Unit at WHO Geneva. His successor, Dr Eduardo Krapf of Buenos Aires, Argentina, stands out in the present context for having taken part in the 1959 ‘Field Studies in the Mental Disorders’ conference in New York, whose proceedings have become a classic in the literature of psychiatric epidemiology (Zubin, 1961). At this conference Erwin Stengel, then Professor of Psychiatry at the University of Sheffield, UK, gave a preliminary report on his international survey of the psychiatric classifications current at that time. He had been asked to undertake the survey by Dr Krapf, and the resulting publication (Stengel, 1959) was the first manifestation of the programme of activities that has continued for over three decades. It is remarkable how much of what was originally suggested and envisaged in these first steps has now come to fruition.

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To those not familiar with the structure, organisation, and programmes of the World Health Organization, the most obvious products of these three decades of activity have probably been the mental health chapters of ICD–8, –9, and –10. These, however, have been only a part (albeit a central one) of a much greater whole: of the four programmes (A, B, C and D) specified at the beginning of this period, only Programme A focused on classifications. Programmes B and C were concerned with comparative field studies of mental disorders, and Programme D with postgraduate training in epidemiology and social psychiatry (these four programmes will be outlined later). Conceiving and planning a programme is a very different activity from carrying it out successfully, and it is in the latter that the achievements of the successive heads of the Geneva unit (see Table 2.1) shine through most clearly. Each leader, in turn, made sure that the sequence of activities was maintained, despite the small number of mental health professionals employed by the Geneva unit and the modest resources available centrally (for instance, there were usually only two or three psychiatrists in WHO Geneva, who were responsible for many other activities in addition to these four programmes). Dr Norman Sartorius, however, is more responsible than most for the continuity and success of the ‘common language’ programmes. He has provided a continuity of efforts and interest, having served in the unit throughout most of the programme, from the days of Drs Lebedev and Tsung-yi Lin in the late 1960s until his retirement in 1994. His remarkable energy and powers of persuasion have also been a vital influence in maintaining the network of centres, collaborators and consultant advisors upon which all the TABLE 2.1 Mental health activities of the World Health Organization in Geneva and responsible officers, years 1949–present Chiefs of the Mental Health Unit 1949–1955 Dr G. Hargreaves (UK) 1956–1963 Dr E. Krapf (Argentina) 1963–1968 Dr P. Baan (The Netherlands) 1969–1970 Dr B. Lebedev (USSR) 1971–1974 Dr F. Hassler (USA) Chief of the Office of Mental Health 1974–1977: Dr N. Sartorius (Yugoslavia) Director of the Division of Mental Health 1977–1994: Dr N. Sartorius 1994–1998: Dr J. A. Costa e Silva (Brazil) Director of the Department of Mental Health (Social Change and Mental Health Cluster) 1999: Dr B. Saraceno


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programmes have depended for their unquestionable success. This was especially true during the last of the three decades in question, when Dr Sartorius was director of the Division of Mental Health. The progression from the original Unit to an Office and finally to a Division conveys, even through the bland terminology of a large organisation such as WHO, a true sense of recognition and achievement.

Phase 1: The early publications The review of psychiatric classifications by Erwin Stengel was the first concrete manifestation of WHO’s interest in that field (Stengel, 1959). Stengel illustrated what he called “the chaotic state of the classifications in current use” by collecting 28 classifications: 11 “official, semi-official or national classifications”, and 17 that were produced on a more individual basis but considered worthy of note. None of the 38 classifications had been published with a clear definition of its terminology, and seeing them all together in one document makes it clear why one of Stengel’s main recommendations was that an international classification should have “a glossary with operational definitions of the various categories ... in as many languages as possible”. His other recommendations were that future international classifications should be conservative rather than innovative, and should somehow be both simple and comprehensive. He also recognised that a classification that followed these guidelines would be likely to be imperfect from the viewpoint of taxonomic principles, but that this was the price to be paid for something that might be acceptable to (and therefore used by) the very diverse population of psychiatrists and other mental health professionals across the world who would comprise its audience. The same year saw the publication of a booklet by Professor D. D. Reid (Epidemiological Methods in the Study of Mental Disorders), which is still a good starting place for anyone wanting a clearly written introduction to the techniques and problems of psychiatric epidemiology (Reid, 1960). Reid was not a psychiatrist, but had a rare combination of expertise in general medical epidemiology and a sympathetic approach to the special problems of psychiatry. His booklet served as a basis for discussion at the meeting of the WHO Expert Committee on Mental Health in 1959, which produced clear recommendations about the need for both an improved international classification and standardised procedures for the description of symptoms and case-finding. Complementary to Reid’s booklet, and published in the same WHO series, was The Scope of Epidemiology in Psychiatry (Lin & Standley, 1962).

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This summarised the main studies then available on the incidence and prevalence of mental disorders; discussed methods most likely to be of use in epidemiological studies of mental disorders; and commented on contemporary hypotheses of the origins of mental disorders. A brief section on factors influencing the duration of mental illnesses also contains comments on the evaluation of various types of treatment. Subsequently, in 1964, the First WHO Scientific Group on Mental Health Research argued that WHO support was essential to developing an acceptable international classification (along the lines stated by Reid). It also linked standardised procedures for casefinding and symptom description. Following a further planning meeting of expert advisers in 1965, more detailed requirements for a ten-year international programme on mental health were produced, as follows (Lin, 1967): 1. The development of a classification of mental disorders, internationally acceptable and capable of uniform application; 2. the development of standardized procedures for case-finding and for the assessment of the severity of illness; 3. the development of a core of trained research personnel; and 4. the development of a network of research centres for the exchange of research data, ideas and skills, and also for training.

These were the bases of the four programmes A, B, C and D outlined in the next section.

Phase 2. Programmes A, B, C and D An overlapping sequence of four mutually complementary projects was then specified, called Programmes A, B, C and D. These were to be initiated and coordinated by the staff of the Mental Health Unit, with some of the staff being involved directly in the research. This direct participation was unusual for WHO Geneva staff, but it has remained a striking and valuable feature of the activities of the mental health division ever since. The four programmes were planned as an overlapping sequence, and it is important to understand how complementary they were meant to be.


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Programme A: Classification: the eight international seminars This programme began in 1965 and dealt with the production and dissemination of international standards for psychiatric diagnosis, classification and statistics, with particular reference to ICD–9 in the first instance (Sartorius, 1976). It took the form of eight seminars at yearly intervals, all of which were attended by a core group of 12 experts from different schools of psychiatry, plus a variety of additional experts from each host centre in turn. The first seminar was held in London in 1965, and set the pattern for the rest of the series by using both written case histories and video-tape ratings to examine problems of symptom assessment and diagnosis (Shepherd et al, 1968). The first seven seminars each covered a major topic of clinical psychiatry, so that by the eighth seminar in Geneva in 1972, the results of the whole series could be taken as an important part of the input for ICD–9 (due to be published by WHO in 1975). The seminars, which were attended by experts from over 40 countries, covered the following subjects:

1965 (London) Functional psychoses, with an emphasis on schizophrenia 1966 (Oslo) Borderline psychosis and reactive psychoses 1967 (Paris) Psychiatric disorders of childhood 1968 (Moscow) Mental disorders of old age 1969 (Washington) Mental retardation 1970 (Basle) Neurotic disorders and psychosomatic disorders 1971 (Tokyo) Personality disorders and drug addiction 1972 (Geneva) Summary, conclusions, recommendations and proposals for further research.

These seminars were concerned primarily with preparations for ICD–9, but some of the same advisers were used in a parallel set of activities which resulted in a glossary for Chapter V of the then current ICD–8. All the chapters of ICD–8 had been published in 1965, and Chapter V was similar to the others in that it took the form of headings, diagnostic terms and code numbers only, with no glossary to guide the reader in using the terms. The preparation of a separate glossary was considered worthwhile since the committee happened to be chaired by Sir Aubrey Lewis, who had also been chairman of a working party that had just produced a glossary to Chapter V of ICD–8 on behalf of the General Register Office of the UK, for national use (HMSO, 1968). The new international glossary had to be tailored towards the existing ICD–8, addressing some of its more obvious deficiencies with the

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forthcoming ICD–9 in mind. For example, the much-criticised category 308, ‘Behaviour Disorders of Childhood’, was given five unofficial but provisionally recommended sub-divisions which closely anticipated the categories that eventually appeared in ICD–9. A first draft of the glossary was produced by Sir Aubrey Lewis for discussion at a meeting in Geneva in 1967; after extensive consultations and further meetings the final form was agreed in 1972 and published as a booklet separate from the other chapters of ICD–8 (WHO, 1974). The glossary to Chapter V of ICD–9 was influenced considerably by this, and by a great deal of additional input from the seven seminars. There was considerable debate among the WHO advisors as to how innovative or even radical ICD–9 might be, but its final form was largely determined by WHO’s overall policy for all ICD–9 chapters. Many chapters of ICD–8 (including chapter V) had been markedly different from ICD–7, so a conservative policy for the whole of ICD–9 was announced by the ICD office. The WHO compilers and their international advisors for all chapters were asked to leave radical changes and major innovations for ICD–10 (Sartorius, 1991). It was agreed, however, that for Chapter V only, a short glossary would be printed in the main ICD volume as an integral part of ICD–9. This was justified by the special problems posed for psychiatry by the relative scarcity of independent measures to guide the diagnostic process. A particularly fruitful part of Programme A was the development of a multi-axial schema for use in child and adolescent psychiatry, as an extension of the single axis approach of Chapter V itself. A work programme led by an international group of advisors (three notable members were Professors Rutter, Shepherd and Eisenberg) drafted and field-tested a tri-axial schema which proved immediately popular and successful with both clinicians and researchers (Rutter et al, 1969, 1975). Right from the start, those involved in Programme A were aware of the need for several other developments, but these would take some time to occur because of the limited resources and personnel. As noted by Kramer et al (1979), there was a need for methods to assess disabilities associated with mental disorders, and also for simple versions of the psychiatric classification for use in primary care. The assessment of disablement was the main focus of attention in a six-centre international collaborative study on disability in persons with schizophrenic illnesses that ran parallel to some of the work described here (Jablensky et al, 1980). Strictly speaking, this disability study was not part of either Programme A or B, but it drew naturally on the existing experience and techniques available as a result of the International Pilot Study of Schizophrenia (IPSS) and other ongoing work; it also made a valuable contribution to the


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methods of assessment used in the ‘Determinants of Outcome of Severe Mental Disorders’ (DOSMED) study (to be described later). The primary health care version of Chapter V eventually formed an important part of the ‘common language’ programme, and has recently completed its international field trials (see the description of the ICD– 10 Primary Health Care Version (ICD–10 PHC) later in this chapter). The success of an earlier WHO international collaborative study on extending strategies for mental health care into primary care (Sartorius & Harding, 1983) was an important incentive for the later development of this ICD–10 PHC. Another four-country collaborative study on depressive disorders, organised in parallel with the Joint Programme by WHO Geneva (Sartorius et al, 1983), also made important contributions: it showed that standardised criteria for depressive disorders could be used successfully across the cultures and languages of the study, and that the clinical characteristics of the patients were broadly similar in the study centres (Thornicroft & Sartorius, 1993). Detailed accounts of Programme A and a list of 29 related publications can be found in the description of the first seminar (Shepherd et al, 1968), and in later reviews of the whole process of development of ICD–9 (Sartorius, 1976; Kramer et al, 1979). Programme B: Pilot studies of cross-cultural methods of assessment and diagnosis Programme B was meant as the testing and practical application phase of some of the diagnostic concepts being developed in Programme A, plus the complementary use of standardised methods of symptom rating. The IPSS, which began in 1966, was a pilot study of mental disorders in different cultures (WHO, 1973, 1975, 1979). The study flourished, and progress was more complete than had originally been anticipated, in that a five-year follow-up study was completed for all centres and some longer ones for some individual centres (Dube et al, 1984; Leon, 1989; Leff et al, 1992). As originally planned, the IPSS led several years later to an epidemiologically based successor (the DOSMED study; Jablensky et al, 1992). These two studies have become well-known partly because of their large scale and international collaborative nature, but partly because of unexpected findings. Only limited aspects of the origins and organisation of these two studies will be commented on here; they have been selected because of their special relevance to the original purpose of the studies and the interpretation of the results. An account of the methods and the results, together with

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comments on sub-studies in several centres on life events and expressed emotions (Day et al, 1987; Katz et al, 1988; Leff et al, 1990), can be found in Chapter 6. It is easy to forget the quite modest aims set originally for the IPSS. In the early 1960s, when the IPSS was being planned, the concepts and techniques implicit in standardised or semi-standardised interviews and rating methods that were then being developed were by no means universally accepted by researchers, even in Europe and the USA. Furthermore, it was not known whether psychiatrists of different educational, cultural and linguistic backgrounds could, by training together, reach the levels of interrater agreement on symptoms and diagnoses that would be required for a successful study. The first essential task in the preparations for the IPSS was to assemble a group of psychiatrists from centres of differing languages, cultures and psychiatric traditions, who shared the English language and a knowledge of European descriptive psychiatry as a means of psychiatric communication. They could then test whether the standardised interviewing and rating methods then becoming available could be applied to patients in their countries of origin, across the potential barriers of culture and language. In formal terms, the aims of the IPSS were as follows (Lin, 1967): 1. The devising of standard research instruments and procedures for case-finding and for the degree of psychiatric impairment in schizophrenia. 2. The demonstration that comparable cases of schizophrenic disorders can be identified in different cultures. 3. The description of the course taken by cases in the period after their firm diagnosis.

Preparations for the IPSS were helped in some important respects by the staff of the US–UK Diagnostic Study (Cooper et al, 1969, 1972; Kramer, 1969; Zubin, 1969). These two studies were quite separate administratively and financially, although they were both aimed at clarifying cross-cultural and cross-national problems associated with the diagnostic process and major mental illnesses. When the centres and principal collaborators of the IPSS were being identified, the US–UK study was already well under way with the preparations for its first comparative study of hospital admissions in London and New York. Its team (which included Dr N. Sartorius as one of the main interviewers in the first Netherne-Brooklyn hospitals admission study) was already experienced in the use of the Present State Examination (PSE). To obtain close comparability between studies


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is one of the main reasons for using instruments such as the PSE, so when this interview was adopted for use by the IPSS it was clearly of mutual benefit for the principal investigators of the IPSS and the US– UK team to carry out some joint training interviews (using the mobile caravan video-tape studio already developed by the US–UK team at the Institute of Psychiatry in London). These overlapping studies also shared senior advisors, including Professors J. K. Wing and M. Shepherd, and both studies owed a great deal to the administrative support and financial influence of Dr M. Kramer of the National Institute of Mental Health of the USA. Eight Field Research Centres (FRCs) had been selected for the IPSS by the beginning of 1966 (Aarhus, Denmark; Agra, India; Cali, Colombia; Ibadan, Nigeria; London, UK; Moscow, USSR; Taipei, Taiwan; Washington, USA). A ninth (Prague, Czechoslovakia) was added in 1967. (Further information about individual staff members and details of all the study schedules can be found in the IPSS references given at the end of this chapter; WHO, 1973, 1975) The IPSS was carried out in three stages (preliminary, initial evaluation, and follow-up). During the preliminary phase, the principal investigators (who had trained together on all the study instruments in London and Geneva) organised their FRC teams, trained their interviewers, and tested all the procedures by selecting and assessing 26 patients: 12 with undoubted schizophrenia, six with doubtful schizophrenia, six with non-schizophrenic functional psychosis (mainly affective psychosis), and two with neurosis. This preliminary phase was completed on schedule in all the FRCs, and even at this early stage it was clear that study aims 1 and 2, as noted above, could be achieved. The initial assessment phase, completed in 1968, took a total of 1202 patients divided more or less equally among the nine FRCs. The study diagnoses were as follows: schizophrenia 811, affective psychosis 164, and other psychoses or nonpsychotic conditions 227. Although it is convenient to categorise the study patients by means of diagnostic labels, it is important to note that they were selected by means of symptoms, and not by means of diagnoses made by local clinicians. Eligible patients had to be aged 15–44, and have psychotic symptoms such as delusions, hallucinations or very strange and inexplicable behaviour which were not due to organic illness, epilepsy, alcohol or drugs, and not associated with mental retardation. Having selected the patients by these symptomatic criteria (plus a six-month local residence criterion to maximise the likelihood of successful follow-up), the study psychiatrists then administered the PSE, followed by the Psychiatric History Schedule and the Sociodemographic Schedule.

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By the time the two-year follow-up was completed and the main tasks of data analysis got under way, the CATEGO computer program was available for the analysis of the PSE data (Wing et al, 1974). This condenses the symptoms into syndromes, categories and classes, which can be used to make comparisons free from the diagnostic variations and biases of individual clinicians. The rules of the programme reflect the symptomatic terminology and diagnostic concepts and biases of the authors of the programme, but these are applied consistently to all patients in all centres, and are evident from the computer program. Data analysis, both centrally and for individual FRCs, relied more upon symptoms and syndromes than diagnoses, although all three levels of analysis were used at different times. The CATEGO syndromes, categories and classes reflect the diagnostic status of the patient as far as this can be represented by the mental state and behaviour recorded by the PSE, but they do not contain information from the other schedules about personal and psychiatric history. These, of course, may have an important influence upon the study diagnosis, which gives a more conventional and comprehensive statement about the patient, but at the cost of potentially including more variation among the centres. But even allowing for this, and for all other problems of data interpretation, there can be no doubt about the clarity of the study’s main finding with regard to schizophrenia: that typical cases of severe forms of the illness were found in all the FRCs without difficulty. This is true however it is defined, and at whatever level of symptoms or syndromes it is conceived. The IPSS was the first large collaborative study to face the problem of how to translate the conventionally accepted symptoms of descriptive European psychiatry into non-European languages. For the IPSS, the PSE was translated into seven languages by developing a system of translation and re-iterative back-translation which depended upon finding the equivalence of meaning (or ‘targetcheck’) rather than merely a literal, word-by-word translation. There are inevitably some grey areas and unsolved problems in this area of translation and equivalence, but only a very small proportion of the items in the study schedules were truly problematic. From the very earliest stages of the study, the many bilingual and often trilingual psychiatrists who worked in the FRCs – most of whom also had cross-cultural educations – had no difficulty in accepting the validity of the cross-cultural and cross-language comparisons that were being made. This early experience with the IPSS demonstrated the need to develop some special, systematic procedures for achieving the best possible equivalence of meaning in the documents of international collaborative studies (Sartorius & Kukyen, 1993; Sartorius, 1995a). Back-translation by bilingual persons who have no


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professional knowledge of psychiatry or mental health issues is an important part of this search for equivalence of meaning. These points – about the selection of patients, about much of the interviewing being done by bilingual and cross-culturally trained psychiatrists, and about the care taken to establish equivalence of meaning in the translation of questions about symptoms – are important when considering the validity of recent criticisms of the interpretation of the results of both the IPSS and the DOSMED studies from the perspective of cultural anthropology (Kleinman, 1987). Whatever the ‘category fallacy’ might be, it does not apply to these studies. In the third or follow-up stage, the original patients were traced and, whenever possible, re-interviewed. The original intention was to do this two years after the initial evaluation (Sartorius et al, 1977; Jablensky et al, 1992), and the follow-up was later extended to five years (Leff et al, 1992). In a few centres there were follow-up studies after 10 or more years (Dube et al, 1984; Leon, 1989), and virtually all the original FRCs are now collaborating with a number of other centres in a 20-year follow-up study, again coordinated by WHO Geneva (Sartorius et al, 1996). In view of the comparatively modest and largely methodological aims of the IPSS, as noted above, no special clinical hypotheses about course and outcome were specified at the start of the study. The study’s general finding (common to all the FRCs) that symptomatically similar patients may differ greatly with regard to course and outcome is interesting in itself, but an altogether more challenging puzzle is provided by the finding that “the course and outcome of schizophrenia differs in the different centres of the study ... and it appears to be less severe in the developing centres” (WHO, 1979). ‘Developing centres’ is the study shorthand for those centres in the so-called developing countries, primarily Agra (India) and Ibadan (Nigeria); high proportions of patients with schizophremia in these centres fell into the good outcome categories, contrasting with low proportions of good outcome patients in Aarhus (Denmark), London and Moscow. The same difference in outcome between the centres in developing and developed countries was also found in the five-year follow-up. This finding was unexpected; if there had been any statements made at the start of the study about predicted outcome, it is likely that expectations of earlier and more complete treatment in the ‘developed’ centres would have led the researchers to predict the opposite of what was found. This unexplained and surprising follow-up result was one of the principal motivations for the DOSMED of Programme C (discussed later), but its importance should not be allowed to obscure the other clinical findings of the IPSS that are central to the usefulness (or

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otherwise) of the traditional distinction between schizophrenia and severe affective disorders. The importance of this issue justifies a quotation from the full report of the IPSS two-year follow-up: The demonstration that the schizophrenic group of patients had a more severe course and outcome than the other patients in the study indicates that symptomatological differentiations are of importance. The finding that when schizophrenic patients have subsequent episodes the episodes are schizophrenic in type and when patients with psychotic affective disorder have subsequent episodes the episodes are affective in type also indicates the predictive usefulness of the clinical classification.

More than 20 years later, and despite modern technology and sophisticated statistical analyses, simple clinical description is still the most useful way of differentiating between these two groups of disorders. The administrative and organisational aspects of the IPSS have also been of lasting significance, in that the collaborative network of FTCs required for the study developed some unique features whose significance goes beyond the immediate findings of the study itself. For those individuals involved directly in the IPSS as either collaborating investigators or advisors, one of the study’s most striking and valuable features was the series of roughly annual meetings held in turn at each of the FTCs. In the 1960s and ’70s, funding was often available at a rather more generous and farsighted level than now. It was possible to have regular meetings, usually attended by two investigators from each FRC, plus a number of external advisors. The participants reported progress, discussed problems, and did inter-rater reliability exercises on PSE interviews and diagnostic procedures. These meetings were not only an invaluable means of maintaining the highest possible standard of data collection, but as the years went by they inevitably produced close professional and personal relationships among the collaborating investigators, the staff of WHO Geneva and the advisors. Once such a network had been established, some or all of the centres collaborated in other WHO studies, such as the DOSMED study (Sartorius et al, 1986; Jablensky et al, 1992) and a Family Planning study (Jablensky, 1984), and the established relationships played an important role in facilitating the technical and scientific work. A variety of later WHO international collaborative studies and programmes have followed similar administrative and collaborative procedures. The existence of the network and its advisors has also made it easier to give advice on study design and instruments to psychiatrists


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and epidemiologists who have carried out studies on mental health in a number of countries, such as the 1982 Chinese National Epidemiological Survey of Mental Disorders (Cooper & Sartorius, 1996). Programme C: Mental disorders in geographically defined populations This programme was envisaged as possible at least five years after Programmes A and B had established a network of collaborating centres containing experienced and trained personnel able to use standardised methods for case finding and assessment. Programme C finally materialised in the form of the WHO Collaborative Study on the Determinants of Outcome of Severe Mental Disorders (DOSMED) (Sartorius et al, 1986; Jablensky et al, 1992); the study was designed in 1975–76 and field work began in 1978. Apart from an increase in the number of FRCs to 12 (see Table 2.2), the DOSMED differed from the IPSS in that: (a) It was epidemiologically based; each FRC defined a catchment area containing at least several hundred thousand persons aged 15–54 years. (b) Only persons developing a new (lifetime first) and possibly schizophrenic illness during a two-year period were included. The aim was to identify and assess all such persons as soon as possible after the onset of their illness, when they came to the notice of any type of local medical or healing service, and whatever pathway they had adopted in order to obtain help. (c) An increased amount of personal, family and sociodemographic information was collected for each subject. (d) Several centres carried out additional studies on the relationships between the onset and any exacerbations of the illness and life events, family expressed emotion, and disability. It was, therefore, a study of the incidence of schizophrenia in terms of contact with a medical service or healing agency, rather than a community survey. The DOSMED was similar to the IPSS in that subjects were selected by symptomatic criteria and not by diagnosis, and residence in the catchment area for at least six months before the onset of the illness was also required. Follow-up for re-assessment in the DOSMED was at both one and two years after the first contact. It was hoped that these extensions of the study aims and design would throw light on some of the reasons behind the unexpectedly better outcome found in the IPSS for people with schizophrenia from the centres in the developing countries. In all the DOSMED

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centres, a great deal of effort was put into identifying and assessing all eligible people, so that conclusions about outcome could be as confident as possible. In the FRCs in well developed urban areas with extensive primary care facilities and hospital out-patient clinics, such as Nottingham and Aarhus, this was much easier than in FRCs in areas where the first contact was more likely to be made with local healers not usually in contact with the orthodox medical services. In such FRCs (notably Agra, Chandigarh, Ibadan and Cali) special efforts were made to contact the local healer network to obtain information about (and permission to interview) possible cases, and a large measure of cooperation was obtained. In addition, ‘leakage studies’ were done in all the FRCs to estimate how many eligible cases might have been missed. The overall conclusion was that these were comparatively few, and are very unlikely to have had a significant effect on the findings of the study. The two main findings of the DOSMED were a confirmation of the better outcome for people with typical schizophrenic illnesses in the developing centres, and that the incidence of schizophrenia is surprisingly similar in all the FRCs, when compared with the very wide variations in incidence found for many physical disorders. Both of these general conclusions are somewhat surprising, but in different ways. The generally better outcome for people in developing countries cannot be explained by any of the additional personal, family or socio-demographic data collected in the DOSMED. If this effect is due to ‘culture’, and no other explanation appears to be likely, then we have yet to identify what aspects of the cultural TABLE 2.2 WHO Field Research Centres (FRCs) collaborating in the International Pilot Study of Schizophrenia (IPSS) and the Study of Determinants of Outcome of Severe Mental Disorders (DOSMED) Country Colombia Czechoslovakia Denmark India

IPSS Cali Prague Aarhus Agra

Ireland Japan Nigeria Taiwan UK USA

Ibadan Taipei London Rochester

USSR

Moscow

DOSMED Cali Prague Aarhus Agra Chandigarh Dublin Nagasaki Ibadan Nottingham Honolulu Washington Moscow


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differences between the centres, the families and the patients are important in this respect. Further studies are clearly indicated, but it seems likely that small-scale and more individually focused investigations would be the most profitable next step, rather than repeats of very large-scale epidemiological surveys. Surprisingly, the finding that the incidence of schizophrenia is fairly similar in the different centres, although by no means identical, has caused more debate than the findings about outcome. The results on incidence are, of course, of interest, but they are a by-product of the need to have as complete a group as possible in order to be able to study all possible outcomes. The differences in incidence that can be described between the centres depend on the definition of schizophrenia that is used (and the study was designed with this in mind). The annual incidence of broadly defined schizophrenia in the centres ranged between 1.5 and 4.2 per 100 000 persons at risk (males and females together) – a difference of almost threefold, and statistically significant. But when a narrower definition of schizophrenia is used, defined by the computer program CATEGO as Class S+ (mainly the ‘first rank’ symptoms), the range is between 0.7 and 1.4 per 100 000 or only a twofold difference, and not statistically significant within the terms of the study. The general conclusion put forward by the authors of the study report is that these figures are ‘similar’, or ‘show absence of marked variation’. This is a long way from suggesting that the rates are the same or identical, or that the findings can be generalised to a claim of a ‘worldwide’ uniformity of incidence rates; surprisingly, this is what some of the subsequent critics of these studies appear to have read into the description of the results (such as Stevens & Wyatt, 1987). The present paper is not the place to go into detail about these issues; these and other mistaken interpretations are dealt with in the response by Jablensky et al (1987). The interest shown in the findings about differences in outcome and similarities of incidence should not be allowed to obscure the many other findings of clinical importance in the IPSS and the DOSMED. In view of the doubts sometimes raised about the usefulness and validity of schizophrenia as a clinical concept, it is important to note that these large-scale, multi-centre and crosscultural studies have confirmed some basic features that do make the concept useful. In all the study areas, the age- and gender-specific curves of incidence follow a similar pattern and there is a general tendency for the onset of schizophrenia to occur later in females than in males. In the context of schizophrenia being separate from affective disorder, relapses run true to type far more often than not, and the

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outcome within the study population for patients with schizophrenia was much less favourable than that for the smaller number of patients with severe affective illness. The DOSMED results also indicate very clearly that on a broad scale, a first episode of schizophrenia is certainly not always associated with a poor prognosis and hospitalisation. Almost a third of the patients in the study were never admitted to hospital, and half had only a single psychotic episode, followed by mainly complete remission over the first two years. Between 15 and 20% of patients in all centres ended up in the worst outcome category, however, which means an unremitting and largely continuous psychotic illness. The main conclusion that has emerged from these studies to date is that however schizophrenia is defined, there is a marked and unpredictable variation in its course and outcome when viewed from the first presenting illness. Only weak predictors of outcome, either good or bad, could be identified in the mass of onset data. Variability and unpredictability therefore remain as major problematic features of the current concepts of schizophrenic illnesses. Another reason why the DOSMED study was unique was that in some centres it explored hypotheses about the effects of the patient’s family and social environment on outcome. Variables were (a) differences in the frequency of life events (Day et al, 1987), (b) differences in the emotional environment (Leff et al, 1990), and (c) differences in the expression and perception of psychosis (Katz et al, 1988). Further analyses of the DOSMED study data are being done in some of the collaborating centres, and some further interpretations and explanations of these findings could well emerge in the near future. The final chapter in the story of the WHO International Collaborative Studies on Schizophrenia and Related Disorders will not be written until the results of the very long-term collaborative followup study are available. This study is now in progress and involves all the patients of the FRCs of both the IPSS and the DOSMED, plus the patients in the six FRCs that took part in the WHO Disability Study (Jablensky et al, 1980). Several additional centres already studying long-standing groups of people with schizophrenia are also collaborating (Sartorius et al, 1996). This combined follow-up study now involves 19 centres, and a total of around 2500 people; the same standardised methods of assessment for mental state and for social and clinical outcome that were used in the original studies are being used again. In the majority of the centres data analysis is still in progress at the time of this writing, but the Nottingham Field Research Centre has already reported its findings. Once more, these illustrate the dangers of making assumptions about the social outcome of schizo-


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phrenia. For instance, contrary to the expectations of the clinicians in charge of the Nottingham patients, 13 years after the onset of their first illness none of the original 99 people was found to be living permanently in hospital accommodation. Ninety-five were traced (67 of whom had originally been given a diagnosis of certain or probable schizophrenia). Nine had died but, of the rest, none was homeless and only two were severely dependent in the sense of living in supervised accommodation. The other 84 were living with family or friends, or alone but independently (Harrison et al, 1994). On the down side, about half of the original 67 people with schizophrenia still had some negative symptoms (Mason et al, 1995). Programme D. Training programmes in epidemiological research techniques For Programme D, a four-month postgraduate training programme was put together by WHO Geneva in consultation with the heads of the FTCs that had taken part in the IPSS, the DOSMED, and the WHO Disability Study. Groups of WHO postgraduate fellows were selected by WHO Geneva for their interest in both the administrative and clinical aspects of the epidemiology of mental disorders. Usually in small groups, they spent defined periods of time at some of the FTCs (mainly Aarhus, Groningen, London and Mannheim), where they studied under the guidance of the director of each FTC. Whenever possible they joined in ongoing research at the FTCs or were given assistance in planning future studies of their own. Two international workshops were also organised by WHO Geneva, the first in 1975 in Tehran and the second in Khartoum in 1977. These resulted in a publication intended as an aid to the planning of future seminars and similar postgraduate courses (Baasher et al, 1982). The most recent example of the continued application of ideas from Programme D was a series of seminars organised jointly by the Division of Mental Health and the Ministry of Health of the People’s Republic of China, in 1980, 1981 and 1982. When the difficult period of isolation and internal strife under the ‘cultural revolution’ came to an end around 1978 and 1979, the staff of the medical colleges were brought together again, and psychiatry was re-established as an essential medical discipline. The Chinese authorities recognised the need to give some priority to psychiatric epidemiology and the practice of psychiatry in primary care settings, and the first of a dozen or so national seminars covering the major aspects of psychiatry and the neurosciences was devoted to psychiatric epidemiology (Cooper, 1982a).

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Phase 3. The joint WHO–ADAMHA project and the development of ICD–10 The joint project had its origins in the late 1970s, the result of a joint initiative by the late Dr Gerald Klerman, the chief administrator of the Alcohol, Drug Abuse and Mental Health Adminstraton (ADAMHA) of the US government, and by Dr Norman Sartorius, Director of the Division of Mental Health, WHO Geneva. From the start, the basic strategy was to recognise the essentially international nature of progress in many aspects of mental health work, particularly for classification and diagnosis. In this joint project the authority and resources of both WHO and ADAMHA have been used to facilitate collaboration within the continuing WHO network of centres and advisers, and also between these advisers and the Task Forces of the American Psychiatric Association (APA) that were organised to develop first DSM–III–R, and later DSM–IV. Of particular importance were groups of researchers with special expertise in the development of standardised research interviews such as the Diagnostic Interview Schedule (DIS; Robins et al, 1981), the PSE (Wing et al, 1974), and the Personality Disorder Examination or PDE (Loranger et al, 1987) (see also Chapter 4). The main aims of the joint project were specified as follows (WHO, 1981): (a) to review the present state of diagnosis and classification in the mental health field; (b) to identify gaps in knowledge, or specific deficiencies in the existing classification systems, which call for coordinated research on a national or international basis; (c) to define priority objectives, types of study design, and mechanisms of coordination for such research. The practical plans prepared by the two agencies consisted of three stages. The first, in 1980 and 1981, were preparations for the second, which was designated as a major international conference of investigators to be held in 1982. The third stage was planned as an ongoing and open-ended programme of collaborative field studies based on the objectives and priorities that would be identified in the first two phases. The development of assessment instruments linked to sets of diagnostic criteria and classification was identified as a central activity in these field studies. These activities continued until 1994, and many hope that this remarkable joint project will have a successor in the form of a further programme of similar collaborative work. The preparations for the conference started in 1979 and involved work by nine scientific groups, each with a membership of 10 to 12 people, chosen to ensure wide international and cultural


33

representation. Each group was in charge of producing a review of recent research in diagnosis and classification in its particular field, and was also given the task of suggesting subjects for future collaborative research. The nine working groups covered all the main areas of clinical psychiatry, with special emphasis on psychiatry in primary care, and on the standardisation of terms used in diagnosis and classification. The reports of the working groups were gathered together and comprised the basic background document of the conference, which was held in Copenhagen in 1982. The conference itself was attended by some 200 psychiatrists (Cooper, 1982b), and played a central role in setting the scene for a number of international collaborative ventures. In effect, the conference and the statement of the aims of the joint project were the start of a new phase of international work on diagnosis and classification that was collaborative rather than adversarial, and which has continued to the present day. This joint project has directly supported the development of a second-generation trio of international standardised research instruments, namely SCAN (Wing et al, 1990), CIDI (Robins et al, 1988), and the IPDE (Loranger et al, 1994) (see Chapter 4), and has had a major impact on the final forms of both Chapter V of ICD–10 and of the DSM–IV, as noted later on. Within this context, the 1980s and early 1990s can be seen as a fruitful period of international collaboration involving two interacting lines of work. First, SCAN and CIDI were developed from the PSE–9 and the DIS, respectively, and the first versions of the IPDE were also produced. The detailed content of these three structured research interviews was then extended and adjusted to cover and match the items required for making a diagnosis in, initially, Chapter V of ICD–9 and DSM–III– R, and more recently Chapter V of ICD–10 and DSM–IV. These classifications themselves were also in development during the last part of this phase. As discussed below, the maximum degree of compatibility between them was maintained during their development, again under the auspices of the joint project. SCAN, CIDI and the IPDE Details of the development, properties and uses of SCAN, CIDI and the IPDE, which are the direct descendants of PSE–9, DIS and PDE, respectively, are described in Chapter 5. All three instruments have undergone extensive international field trials, and a feature of the final versions of SCAN and CIDI is their coverage of alcohol and drug misuse disorders. Comments here are confined to their basic properties, and some relationships between SCAN and CIDI that need emphasis.

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SCAN is centred around PSE–10, so it uses the semi-structured, partly standardised interviewing style of its predecessor, PSE–9; this is methodical and rigorous, but still retains clinical flexibility. In contrast, CIDI uses the same highly standardised and comparatively inflexible questionnaire approach as the DIS, as is appropriate for use by lay (although trained) interviewers. SCAN and CIDI are thus different ways of recording the answer to the same initial question, in that the CIDI interviewer rates the reply of the subject to the standard question and standard probes, whereas in SCAN the interviewer makes a clinical judgement as to whether the symptom in question is present or not. This is done by taking into account the answers to the question in the schedule, plus the answer to any other questions that the interviewer judges appropriate to ask in the light of clinical experience and detailed knowledge of the PSE–10 glossary of definitions. Although they have these differences in interviewing and rating, SCAN and CIDI can be viewed as complementary in terms of study design and practical application. For large-scale epidemiological surveys in which only a few subjects can be expected to have severe mental disorders, CIDI has the advantage of cheapness. For more intensive clinical assessments of subjects who are already patients or who are likely to have a number of complicated symptoms, SCAN offers the advantage of more considered judgements about the presence and severity of symptoms, but at much greater professional cost. In spite of these differences in style and origin, SCAN and CIDI have a very large proportion of their symptom items in common, because both of them cover almost all the disorders in both Chapter V of ICD–10 and DSM–IV (except for the personality disorders), and the contents of these two classifications are remarkably alike (Cooper, 1995). This similarity in content is convenient, but it can produce problems for the unwary. It has been amply demonstrated that many mental health professionals such as nurses, psychologists and social workers can, with training, use the non-psychotic sections of the PSE to a good standard; nor is it unusual to find psychiatrists using the CIDI (although, if they follow the rules, they will not be using the flexible clinical interviewing style in which they have been trained). To the uninitiated, it may now seem that there should be no significant differences between data sets produced by these two interviews. But this is a dangerous assumption which is likely to lead not only to sub-optimal use of research skills and interviewing time but also to misunderstandings about differences in the meaning of data obtained from the two interviews. Researchers should always remember the different origins and purposes of these two instruments, never forgetting that CIDI relies on the assumption


35

that voiced complaints can be used as the equivalent of inferred symptoms, and has been developed in a top-down fashion in that the criteria of disorders have been turned into questionnaire items. This is in contrast to SCAN, which is based on defined symptoms that are not necessarily the same as the subject’s complaints, or even about the same topic. Many of the symptoms are then used in a bottom-up fashion to derive syndromes, categories, classes, disorders and diagnoses. Much further work is required on an important question(Burke, 1986): for what disorders and under what conditions of use do these two instruments produce equivalent results? The limited number of comparative studies that have been done to date (Anthony et al, 1985; Folstein et al, 1985; Helzer et al, 1985; Robins, 1985; Farmer et al, 1987) show that there is both good news and bad news in these comparisons, as might be expected. All researchers contemplating the use of either of these interviews in a psychiatric study should take a careful look at the comparative studies just listed, and preferably carry out one of their own under local conditions. Some of these problems are probably unavoidable at the moment, because of the unsatisfactory nature of the current concepts upon which most psychiatric disorders and diagnoses are based. Nevertheless, whatever viewpoint is taken about these problems of equivalence, there is no doubt that SCAN, CIDI and the IPDE are remarkable technical achievements. They certainly provide opportunities for data collection that will allow comparisons between different investigations to be made with greater confidence than has been possible in the past. They also provide a framework for the further investigation of both the symptomatic basis of psychiatric diagnoses and of the effect upon this information of the methods by which the information is obtained. The contents of the IPDE are derived from the Personality Disorders sections of both ICD–10 and DSM–IV, so it allows the production of symptom profiles and the identification of disorders contained in both the classifications. This is probably the least well understood area of current psychiatric knowledge, and the length and complexity of the interview and ratings reflect this. Nevertheless, the IPDE is a most valuable beginning in this particularly difficult field, and it is possible that the analysis of data sets now being obtained through its use will lead the way towards a much needed and quite radical revision of ideas about how best to describe and classify disorders of personality. Researchers wishing to use SCAN, CIDI or the IPDE need to attend a WHO-sponsored course well in advance of the start of their study. This training is now available in English, German, French, Spanish, Arabic, Japanese, Chinese, Portuguese, Greek, Kannada, Turkish,

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Dutch and Italian, at WHO Field Research Centres or National Collaborating Centres (see Chapter 5). Substantial progress has also been made in the development of linguistically and culturally appropriate ways of obtaining information about use and misuse of alcohol and drugs (Room et al, 1995). These topics form large sections of the SCAN and CIDI interviews, in addition to being important in their own right, as discussed in Chapter 11. The development of Chapter V of the ICD–10 The 10-year process that has resulted in Chapter V of ICD–10 has been the centrepiece of the ‘common language’ plan; this new international classification has been influenced by, or has had an influence on, virtually every other part of the activities of the Joint Project. From the beginning, the project organisers and many of those attending the Copenhagen conference had it in mind that everyone would benefit if ICD–10 and DSM–IV could be made as similar and as compatible as possible. This policy recently became overt, as manifested by the meetings between the producers of ICD–10 and DSM–IV (see below). The extent and complexity of the process that led to the present Chapter V of ICD–10 are well illustrated by a collection of papers published in 1988 (Sartorius et al, 1988). These consist of: (a) a discussion of theory and strategy policies that affect both the whole of the ICD and the special requirements for Chapter 5; (b) comments on the structure and presentation of contemporary psychiatric classifications; (c) a description of the procedure for the field trials of the Clinical Descriptions and Diagnostic Guidelines version of Chapter V; and (d) proposals for a multi-axial version. The production of Chapter V, traditionally reserved in the ICD for the classification of mental disorders, had to follow the timetable and general rules of the overall ICD, which now has 21 chapters. After the production of ICD–9 it was judged that the 10-year period previously existing between major revisions of the whole ICD had become inappropriate for future revisions, due to both the rapid increase in international medical knowledge and the increasing use of ICD and related information systems by WHO member states. Chapter V of ICD–10 was therefore given about three times as much classification space as it had in ICD–9, and much of this space is unused for the moment. This will allow future compilers to make changes on a piecemeal basis, as suggestions emerge for revisions to existing categories or for the addition of new ones due to advances in knowledge. This is a more practical strategy than relying on regular, coordinated


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across-the-board revisions, as in the past. It seems likely that the new Chapter V of ICD–10 will remain in its present overall form for some 15 or 20 years before major revisions are attempted. ICD Chapter V and its family of documents Because the classification has to accommodate many and varied applications, it must be widely acceptable and easy to use. It has to reflect accepted advances in psychiatric knowledge, but it must not be unduly influenced by current fashions in psychiatric practice or by potentially controversial viewpoints, however enthusiastically these are put forward by the experts of the day from wealthy or influential institutions and countries. These requirements meant that there was no way to avoid a rather lengthy development process of widespread international consultations. An early decision was made to follow a strategy of ‘different versions for different purposes’, and priority was given to development of the full clinical version, entitled ‘Clinical Descriptions and Diagnostic Guidelines’ (CDDG). This process was started by the Division of Mental Health in Geneva in 1982. More than 50 individual experts in a wide variety of countries were asked to provide first drafts and suggestions for the main sections of the new classification; this input was then edited and brought together into one document, which was circulated to another 200 individual experts for further development and comments in 1983 and 1984. The World Psychiatric Association then gave invaluable help by circulating a second draft to all its member societies and associations, which provided another set of comments and criticisms. The resulting draft then underwent extensive field trials in 1987 and 1988 (Burke, 1988; Sartorius et al, 1993). This testing took place at 112 field trial centres (FTCs) in 39 countries, and was coordinated by 12 regional field trial coordinating centres (FTCCs). Overall, 711 clinicians conducted 15 302 assessments, following a simple protocol provided by WHO Geneva. Another labour-intensive task for this uniquely large operation was the translation of the classification and the field trial documents into six languages. This was done mainly by the directors of those FTCCs responsible for the groups of FTCCs using the languages concerned (French, German, Spanish, Arabic, Chinese and Japanese; see Appendix 2 to Chapter 5). Using the extensive input from the field trials, plus other comments and feedback that had been continuously received over the years from many individuals and organisations, the final version of the Clinical Descriptions and Diagnostic Guidelines (CDDG) was produced in 1989 (WHO, 1992a).

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From this full clinical version of the classification, two other versions of the text were then developed. First, a shortened and simplified version of the descriptions of clinical concepts was required for inclusion in the whole, 21-chapter ICD volume, as the ‘official’ glossary to Chapter V. This glossary is approximately the same length as that in ICD–9, and is shorter and simpler than the CDDG so as to facilitate compatibility with other existing and future national psychiatric classifications. Second, a set of diagnostic criteria for research (DCR– 10) was developed directly from the clinical descriptions and diagnostic guidelines (WHO, 1993a). This meant introducing more specific statements about numbers of symptoms required for a firm diagnosis and about the duration of the symptoms; tightening up of some of the descriptive wording; and omitting most of the ‘other’ and all of the ‘not otherwise specified’ categories. A list and glossary of the so-called ‘culture-specific’ disorders was also produced as an appendix to the DCR–10, in the hope of encouraging research on their epidemiology and defining characteristics. The DCR–10 was then subjected to extensive international field trials, similar to (although on a somewhat smaller scale than) those for the CDDG (Sartorius et al, 1995). Great care has been taken to ensure that both of these derived classifications are compatible with the basic clinical classification, even though they are somewhat different in form because of their different uses. Like other published diagnostic criteria for research, the research criteria of ICD–10 are deliberately restrictive; their use allows the selection of groups of individuals whose symptoms and other characteristics are as similar as possible in the context of the research study that is being carried out. This maximises the homogeneity of the group and the likelihood of positive findings, but limits the generalisations that can be made. Following these first three versions of the new classification, a number of other instruments and documents were prepared (or are currently in preparation) by the Division of Mental Health in Geneva in order to facilitate use of ICD–10 Chapter V in many different settings. These fall into three groups: 1. Versions of Chapter V itself, modified or with additional axes, prepared for specialist users within the mental health disciplines (namely the Primary Health Care Version of Chapter V (WHO, 1996b), and one multi-axial system each for adult general psychiatry (Janca et al, 1996; WHO, 1997), child psychiatry (WHO, 1996a), and mental retardation. 2. Documents that provide users of any of these versions with additional explanations, descriptions and definitions of the concepts and terms contained in Chapter V. These consist of the Lexicon of Mental Health Terms (WHO, 1994b; Janca & Sartorius,


3.

39

1995), the Lexicon of Cross-cultural Terms in Mental Health (Westermeyer et al, 1995), the Lexicon of Alcohol and Drug Terms (WHO, 1994c), the ICD–10 Symptom Glossary for Mental Disorders (WHO, 1994d), and the ICD–10 Symptom Checklist (Janca et al, 1993; Janca & Hiller, 1996). Other aids to the use of Chapter V. These include the ICD–10 ‘cross-walks’ to Chapter V of ICD–8 and ICD–9, which give the nearest equivalent terms; the ICD–10 Chapter V Case-book, which illustrates its clinical use in patients from a variety of cultures; ‘adaptations’ of ICD–10 for both psychiatry and neurology, which bring together into one compound volume those sections of ICD–10 that are most relevant to these disciplines; ‘fascicles’, which bring together those parts of Chapter V and other chapters of ICD–10 most relevant for those with special interests, such as psycho-geriatrics, headaches and cerebrovascular disorders; and conveniently sized guides (Sartorius, 1995b) and paperbacks (Cooper, 1994) that act as quick-reference sources for any type of user. The complete ‘family’ of documents associated with Chapter V is listed in Table 2.3. Out of these many aids to the use of Chapter V, a few deserve special mention here.

Psychiatry in primary care (ICD–10–PHC) This short, simple version for use in primary care (ICD–10–PHC) is now available, following international field trials (Ustun et al, 1995). This is of great potential importance in a global perspective, since the majority of the world’s population receives its psychiatric care in the setting of primary care services. This short version of the new classification is presented quite differently from the other versions and it is limited to a booklet which covers only the 24 most frequently occurring disorders seen in primary care (WHO, 1996b). For each of these, on one page the physician is given succinct advice about presentation and diagnostic features, and on the opposite page are notes on topics such as essential information for patient and family, counselling techniques, indications for drugs and indications for specialist referral. The user of this booklet thus obtains the educational benefit of becoming familiar with the ICD–10 terms used for the most common disorders while, at the same time, being offered options and reminders that should help in the management of the individual patient. The booklet also contains a very brief version of the classification of only six categories for use by primary health care workers who are not physicians.

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Child psychiatry and mental retardation The success of the ICD–9 multi-axial schema for child psychiatry (Rutter et al, 1975) has led to the production of an equivalent for ICD– 10 (WHO, 1996a). The psychiatry of mental retardation (or learning disability) also has special needs, as acknowledged in the introductory remarks to category F7 (Mental Retardation) of the CDDG. A multiaxial expansion of the comparatively brief descriptions given there for the different degrees of mental retardation was envisaged from the beginning, and such a scheme is now in preparation. Disorders due to alcohol and drugs One of the most recently completed parts of the joint project concerning alcohol and drug disorders deserves special comment because of the unusual amount of effort put into elucidating problems of cross-cultural equivalence and meaning of terms. The study on ‘Crosscultural Applicability of Research on Assessment and Diagnosis of Substance Use Disorders’ (CAR ) (Bennet et al, 1993; Room et al, 1995) and the WHO programme on this topic are described in Chapter 11. Relationships between ICD–10 and DSM–IV One of the basic ideas behind the joint project, when it began around 1980, was that these two classifications should not contain unnecessary TABLE 2.3 The ICD–10 Chapter V Family of Documents i. ii. iii. iv. v. vi. vii. viii. ix. x. xi.

Clinical Descriptions and Diagnostic Guidelines (CDDG). Short Glossary for main ICD volume. Diagnostic Criteria for Research (DCR–10). Short and Simple Classification for use in Primary Care (ICD–10–PC). Multi-Axial Schema for the psychiatry of: (a) General Adults; (b) Children and Adolescents; (c) Mental Retardation. ICD–10 Symptom Checklist. ICD–10 Symptom Glossary for Mental Disorders. Clinical Guides (“Adaptations”) and Fascicles of ICD–10 for: (a) Neurology; (b) Headache; (c) Cerebrovascular disorders; (d) Psycho-geriatrics. Lexicon of Psychiatric and Mental Health Terms, 2nd edition (1994). Lexicon of Cross-cultural Terms in Mental Health. ICD–10 Casebook.

Additional documents: (i) Understanding the ICD–10. (ii) Pocket Guide to ICD–10 Classification of Mental and Behavioural Disorders.


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differences. This guiding principle led to a series of four roughly annual meetings, held under the auspices of ADAMHA, and organised by NIMH (Dr D. Regier and colleagues) between 1988 and 1992. At these meetings the leaders of the APA Task Forces that were developing the various sections of DSM–IV were able to discuss their progress with a selection of WHO advisors who were coordinating the work (in several languages) on the development of ICD–10. Whenever possible, the same concepts, diagnostic terms, descriptions, and even phrases were agreed for use in both classifications, and reasons were identified for those differences that remained. The result is that there are surprisingly few differences of any magnitude between the final versions of the two classifications; those remaining are largely the result of the different influences to which the classifications are subject (Regier et al, 1994). WHO Geneva has an obligation to produce a ‘common language’ for a diverse and international set of users. In contrast, the DSM–IV is influenced by the scientific, clinical, administrative and financial priorities of its parent organisation, the American Psychiatric Association. Those outside psychiatry are unlikely to be struck by the differences between the contents of ICD–10 and DSM–IV, but they will immediately notice a difference in presentation, due to WHO’s policy of ‘different versions for different purposes’. Only research experts, understandably dedicated to the details of their favourite disorders, are likely to feel uncomfortable about the differences they discover. (Comments on the differences can be found elsewhere, such as in Appendix D of the full version of DSM–IV, and in Cooper, 1995). Most clinicians should be relieved to see the similarities in the way the great majority of disorders are described and defined in the two classifications.

The need for continuity The success of the programmes of work that have been described here indicates the wisdom of the planners of 30 years ago, and it also pays tribute to the energy and perseverance of the mental health staff of WHO Geneva, led in recent decades by Dr Norman Sartorius. Of equal importance, the continuation of the many activities comprising the programmes has relied upon the efforts of hundreds of collaborating mental health workers in many countries. Most of these have been psychiatrists with full schedules of research and clinical work in addition to their WHO commitments; that they have seen fit to join in these extra international studies speaks for the obvious sense and utility of the WHO programmes. It is to be hoped that current and future

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generations of psychiatrists and other mental health workers will find a similar supply of resources and energy that will enable this type of international collaborative work to continue. Any sentiment that we are now at the end of an era must be dismissed as mistaken and pessimistic, and plans need to be prepared for another 30 years of international collaboration.

Acknowledgements Thanks are due to Dr A. Janca and Dr J. van Drimmelen for information about some aspects of the most recent parts of the WHO ‘common language’ programme.

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FARMER , A., K ATZ , R., M C G UFFIN , P., et al (1987) A comparison between the Present State Examination and the Composite International Diagnostic Interview. Archives of General Psychiatry, 44, 1064–1068. F OLSTEIN , M., R OMANOSKI , A. J., N ESTADT , G., et al (1985) Brief report in the clinical reappraisal of the Diagnostic Interview Schedule carried out at the Johns Hopkins site of the Epidemiological Catchment Area Program of the NIMH. Psychological Medicine, 15, 809–814. HARRISON , G., M ASON , P., G LAZEBROOK , C., et al (1994) Residence of an incidence cohort of psychotic patients after 13 years of follow-up. British Medical Journal, 308, 813–816. HELZER, J. E., ROBINS, L. N., MCEVOY, L. T., et al (1985) A comparison of Clinical and Diagnostic Interview Schedule diagnoses. Archives of General Psychiatry, 42, 657–666. HMSO (1968) A Glossary of Mental Disorders: Studies on Medical and Population Subjects (No. 22). London: General Register Office. JABLENSKY, A. (1984) Mental health and female sterilization: A WHO collaborative prospective study (joint authorship report). Journal of Biosocial Science, 16, 1–21. ——, S CHWARTZ , R. & T OMOV , T. (1980) WHO Collaborative Study on Impairments and Disabilities Associated with Schizophrenic Disorders. Acta Psychiatrica Scandinavica, 62 (Suppl. 285), 152–163. ——, S ARTORIUS , N., H IRSCHFELD , R., et al (1983) Diagnosis and classification of mental disorders and alcohol- and drug-related problems: a research agenda for the 1980’s. Psychological Medicine, 13, 907–921. ——, ——, K ORTEN , A., et al (1987) British Journal of Psychiatry, 151, 408–409 (correspondence). ——, ——, E RNBERG , G., et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine, Suppl. 20. JANCA, A., U STUN , T. B., E ARLY , T. S., et al (1993) The ICD–10 Symptom Checklist: a companion to the ICD–10 classification of Mental and Behavioural Disorders. Social Psychiatry and Psychiatric Epidemiology, 28, 239–242. ——, —— & S ARTORIUS , N. (1994) New versions of World Health Organization instruments for the assessment of mental disorders. Acta Psychiatrica Scandinavica, 90, 73–83. —— & H ILLER , W. (1996) ICD–10 checklists – a tool for clinicians’ use of the ICD–10 Classification of Mental and Behavioural Disorders. Comprehensive Psychiatry, 37, 1–9. —— & S ARTORIUS , N. (1995) The World Health Organization’s recent work on the lexicography of mental disorders. European Psychiatry, 10, 321–325. ——, K ASTRUP , M., K ATSCHNIG , H., et al (1996) The ICD–10 multiaxial system for use in adult psychiatry: structure and applications. Journal of Nervous and Mental Disease, 184, 191–192. KATZ , M., M ARSELLA , A., D UBE , K. C., et al (1988) On the expression of psychosis in different cultures: schizophrenia in an Indian and in a Nigerian community. A report from the World Health Organization project on the determinants of outcome of severe mental disorders. Culture, Medicine and Psychiatry, 12, 331–355. KLEINMAN, A. (1987) Anthropology and psychiatry: the role of culture in cross-cultural research on illness. British Journal of Psychiatry, 151, 447–454. KRAMER, M. (1969) Cross-national study of diagnoses of the mental disorders: the origin of the problem. American Journal of Psychiatry, 125 (Suppl.), 1–11. ——, S ARTORIUS , N., J ABLENSKY , A., et al (1979) The ICD–9 classification of mental disorders: a review of its development and contents. Acta Psychiatrica Scandinavica, 59, 241–262. L EFF , J., W IG , N., B EDI , H., et al (1990) Relatives’ expressed emotion and the course of schizophrenia in Chandigarh: a two-year follow-up of a first-contact sample. British Journal of Psychiatry, 156, 351–356. ——, S ARTORIUS , N., J ABLENSKY , A., et al (1992) The International Pilot Study of Schizophrenia: five year follow-up findings. Psychological Medicine, 22, 131–146.

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LEON , C. (1989) Clinical course and outcome of schizophrenia in Cali, Colombia. A 10 year follow-up study. Journal of Nervous and Mental Disease, 177, 593–606. LIN , T. (1967) The epidemiological study of mental disorders. WHO Chronicle, 21, 503– 516. —— & S TANDLEY , C. C. (1962) The Scope of Epidemiology in Psychiatry. Public Health Papers No. 16. Geneva: World Health Organization. L ORANGER , A., S USMAN , V. L., O LDHAM , J. M., et al (1987) The Personality Disorder Examination: a preliminary report. Journal of Personality Disorders, 1, 1–13. ——, S ARTORIUS , N., A NDREOLI , A., et al (1994) The International Personality Disorder Examination (IPDE): the WHO/ADAMHA international pilot study of personality disorders. Archives of General Psychiatry, 51, 215–224. MASON, P., HARRISON, G., GLAZEBROOK, C., et al (1995) Characteristics of outcome of schizophrenia at 13 years. British Journal of Psychiatry, 167, 596–603. PULL, C. & WITTCHEN, H. U. (1991) CIDI, SCAN, and IPDE: structured diagnostic interviews for ICD–10 and DSM–IV. European Psychiatry, 6, 277–285. REGIER , D. A., K AELBER , C. T., R OPER , M. T., et al (1994) The ICD–10 clinical field trials for mental and behavioural disorders: results in Canada and the United States. American Journal of Psychiatry, 151, 1340–1350. REID , D. D. (1960) Epidemiological Methods in the Study of Mental Disorders. Public Health Papers No. 2. Geneva: World Health Organization. ROBINS, L. N. (1985) Epidemiology: reflections on testing the validity of psychiatric interviews. Archives of General Psychiatry, 41, 918–925. ——, H ELZER , J. E., C ROUGHAN , J., et al (1981) National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics and validity. Archives of General Psychiatry, 38, 381–389. ——, WING, J. K., WITTCHEN, H. U., et al (1988) The Composite International Diagnostic Interview. Archives of General Psychiatry, 45, 1069–1077. ROOM, R., JANCA, A., BENNETT, L. A., et al (eds) (1995) WHO cross-cultural applicability research on diagnosis and assessment of substance use disorders: an overview of methods and selected results. Addiction, 91, 199–220. R UTTER , M., L EBOVICI , S., E ISENBERG , L., et al (1969) A tri-axial classification of mental disorders in childhood. Journal of Child Psychology and Psychiatry, 10, 41–61. ——, S CHAFFER , D. & S HEPHERD , M. (1975) A Multi-axial Classification of Child Psychiatric Disorders. Geneva: World Health Organization. S ARTORIUS , N. (1976) Classification: an international perspective. Psychiatric Annals, 6, 359–367. —— (1989) Recent research activities in the WHO’s mental health programme. Psychological Medicine, 19, 233–244. —— (1991) The classification of mental disorders in the Tenth Revision of the International Classification of Diseases. European Psychiatry, 6, 315–322. —— (1992) Research Activities in WHO’s Mental Health Programme (WHO/MNH 92.9). Geneva: World Health Organization. —— (1993) WHO’s work on the epidemiology of mental disorders. Social Psychiatry and Psychiatric Epidemiology, 28, 239–242. —— (1995a) SCAN Translation. In A Reference Manual for SCAN (eds J. K. Wing, N. Sartorius & T. B. Ustun). Cambridge: Cambridge University Press. —— (1995b) Understanding the ICD–10. London: Science Press. ——, Jablensky, A. & Shapiro, R. (1977) Two year follow-up of the patients included in the WHO International Pilot Study of Schizophrenia: preliminary communication. Psychological Medicine, 7, 529–541. ——, Davidian, H., Ehrenberg G., et al (1983). Depressive Disorders in Different Cultures. Geneva: World Health Organization.


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—— & H ARDING , T. (1983) The WHO Collaborative Study on Strategies for Extending Mental Health Care. I: the genesis of the study. American Journal of Psychiatry, 140, 1470–1473. ——, J ABLENSKY , A., K ORTEN , A., et al (1986) Early manifestations and first contact incidence of schizophrenia in different cultures: a preliminary report on the evaluative phase of the WHO Collaborative Study on Determinants of Outcome of Severe Mental Disorders. Psychological Medicine, 16, 909–928. ——, ——, C OOPER , J. E., et al (1988) Psychiatric classification in an international perspective. British Journal of Psychiatry, 152 (Suppl. 1), 3–52. ——, K AELBER , C., C OOPER , J. E., et al (on behalf of the participating investigators) (1993) Progress towards achieving a common language in psychiatry. Results from the field trial of the Clinical Guidelines accompanying the WHO Classification of Mental and Behavioural Disorders in ICD–10. Archives of General Psychiatry, 50, 115–124. —— & K UKYEN , W. (1993) Translation of Health Status Instruments. In Quality of Life Assessments in Health Care Settings. Berlin: Springer-Verlag. ——, U STUN , T. B., K ORTEN , A., et al (1995) Progress towards achieving a common language in psychiatry. II: results from the international field trials of the ICD–10 Diagnostic Criteria for Research for Mental and Behavioural Disorders. American Journal of Psychiatry, 152, 1427–1437. ——, G ULBINAT , W., H ARRISON , G., et al (on behalf of the collaborating investigators) (1996) Long-term follow-up of schizophrenia in 16 countries: A description of the International Study of Schizophrenia conducted by the World Health Organization. Social Psychiatry and Psychiatric Epidemiology, 31, 249–258. SHEPHERD, M., BROOKE, E. M., COOPER, J. E., et al (1968) An experimental approach to psychiatric diagnosis: An international study. Acta Psychiatrica Scandinavica, 44 (Suppl. 201). STENGEL, E. (1959) Classification of mental disorders. Bulletin of the WHO, 21, 601–663. STEVENS , J. & W YATT , R. J. (1987) British Journal of Psychiatry, 151, 131–132 (correspondence). THORNICROFT , G. & S ARTORIUS , N. (1993) The course and outcome of depression in different cultures: 10-year follow-up of the WHO Collaborative Study on the Assessment of Depressive Disorders. Psychological Medicine, 23, 1023–1032. USTUN, T. B., GOLDBERG, D., COOPER, J. E., et al (1995) A new classification for mental disorders with management guidelines for use in primary care. British Journal of General Practice, 45, 211–215. WESTERMEYER , J., J ANCA , A. & S ARTORIUS , N. (1995) Lexicon of Cross-cultural Terms in Mental Health. Geneva: World Health Organization. WHO (1973) The International Pilot Study of Schizophrenia. Vol I. Geneva: World Health Organization. —— (1974) Glossary of Mental Disorders and Guide to their Classification (in conjunction with the International Classification of Diseases, 8th Revision). Geneva: World Health Organization. —— (1975) Schizophrenia: A Multinational Study. Public Health Papers No. 63. Geneva: World Health Organization. —— (1979) Schizophrenia: An International Follow-up Study. Chichester: John Wiley & Sons. —— (1981) Current State of Diagnosis and Classification in the Mental Health Field: a report from the WHO/ADAMHA Joint Project of the Diagnosis and Classification of Mental Disorders and Alcohol- and Drug-related Problems (WHO/MNH/81). Geneva: World Health Organization. —— (1992a) The ICD–10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization. —— (1992b) International Personality Disorder Examination. Geneva: World Health Organization.

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—— (1993a) The ICD–10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization. —— (1993b) The Composite International Diagnostic Interview, Core Version 1.1. Washington, DC: American Psychiatric Press. —— (1994a) Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Washington, DC: American Psychiatric Association. —— (1994b) Lexicon of Psychiatric and Mental Health Terms, 2nd edn. Geneva: World Health Organization. —— (1994c) Lexicon of Alcohol and Drug Terms. Geneva: World Health Organization. —— (1994d) ICD–10 Symptom Glossary for Mental Disorders. Geneva: World Health Organization. —— (1996a) Multiaxial Classification of Child and Adolescent Psychiatric Disorders: the ICD– 10 Classification of Mental and Behavioural Disorders in Children and Adolescents. Cambridge: Cambridge University Press. —— (1996b) Diagnostic and Management Guidelines for Mental Disorder in Primary Care; ICD– 10 Chapter V Primary Care Version. Berne: Hogrefe and Huber (for WHO). —— (1997) Multi-axial Presentation of ICD–10 for Use in Adult Psychiatry. Cambridge: Cambridge University Press. —— & ADAMHA (Alcohol, Drug Abuse and Mental Health Administration) (1985) Mental Disorders, Alcohol- and Drug-Related Problems: International Perspectives on Their Diagnosis and Classification (International Congress Series 699). Amsterdam: Excerpta Medica. W ING , J. K., C OOPER , J. E. & S ARTORIUS , N. (1974) The Measurement and Classification of Psychiatric Symptoms. Cambridge: Cambridge University Press. ——, B ABOR , T., B RUGHA , T., et al (1990) SCAN: Schedules for Clinical Assessment in Neuropsychiatry. Archives of General Psychiatry, 47, 589–593. ZUBIN , J. (ed) (1961) Field Studies in the Mental Disorders. New York: Grune and Stratton. —— (1969) Cross-national Study of Diagnosis of the Mental Disorders: Methodology and Planning. American Journal of Psychiatry, 125 (Suppl. 10), 12–20.

Issues in contemporary psychiatry

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Beyond ICD–10 and DSM–IV: issues in contemporary psychiatry ASSEN JABLENSKY

Introduction I have always felt that with mental patients, one of the most important things one can do for them, in nearly all cases, is to know them and to be able to distinguish them from all other human beings. A psychiatric diagnosis may be a severe obstacle to the acquirement of this goal. (E. Strömgren, 1982)

Scientific research in psychiatry over the past 20 years presents a picture of eminent success. There are dramatic advances in the application of molecular neuroscience to the study of neurotransmitter function and brain receptors; in the unravelling of the role of neurotrophic and growth factors in the development of the brain; in the use of advanced mathematical and modelling methods for understanding brain connectivity, information processing, attention and memory. Brain imaging technologies, coupled with neuropsychological and neurophysiological measurements, are already providing insights into the performance of specific cognitive operations and into the cerebral processes involved in the production of psychopathological symptoms. Genetics has supplied strong evidence for a significant, complex genetic contribution to the aetiology of many psychiatric disorders. Molecular genetics is now closing in on the genomic basis of Alzheimer’s disease, and promising findings are emerging in the search for susceptibility genes associated with schizophrenia and bipolar affective disorders. 47

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Psychiatric research now appears to be firmly rooted in the general biomedical paradigm that has proved to be highly successful in advancing knowledge and intervention capabilities in the rest of medicine. As Guze put it in 1989: Psychiatry is a branch of medicine, which in turn is a form of applied biology ... I have elsewhere characterized this approach as the Medical Model emphasizing thereby that psychiatry, as a medical discipline, should be based as the rest of medicine on modern biological science.

Recent advances in psychiatric research have been linked to profound changes in the field of psychiatric diagnosis and classification over the past 20 years. The changes were initiated first by WHO’s Programme A in the early 1970s and reinforced later on by the ‘neo-Kraepelinian revolution’ in the USA, with the worldwide impact of DSM–III. It seems as if psychiatry has finally freed itself from the tower of Babel of incommensurate diagnostic concepts, terminologies and classifications, by embracing a ‘common language’ – or rather two, fairly similar languages – embodied now by DSM–III (DSM– IV) and ICD–10. There can be no doubt that the introduction of a common framework of classificatory concept, definitions and explicit diagnostic criteria is a major step forward, which can result in several kinds of appreciable gain:

facilitation of collaborative research, thanks to the improved comparability of clinical samples, and the possibility to pool databases and exchange information; an improvement of the reliability and, possibly, validity of statistical reporting on diagnoses, contacts with services, admissions and discharges, treatment outcomes, and levels of disability and handicap in psychiatric populations; improvements in the teaching of psychiatry due to the adoption of an international reference system; better communication with the public by making psychiatric diagnosis somewhat ‘transparent’ to non-professionals and by demystifying the diagnostic process.

At the scientific level, perhaps the main merit of systems like DSM–IV and ICD–10 lies in the specification of diagnostic criteria. Admittedly, many of these criteria are still provisional and may be arbitrary but, at the very least, they are stated in a testable format and are amenable to validation or rejection, as part of a normal process of incremental growth of knowledge through hypothesis testing.


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However, the recognition of the importance of such developments, and of the potential benefits of the fully standardised diagnostic and classification systems in psychiatry, should not prevent us from critically examining their possible adverse side-effects. The issues to consider here stem from the fact that the introduction of the new, explicit diagnostic criteria and categories in psychiatry takes place in the context of a discipline which lacks inner conceptual coherence and which is readily influenced by ideologies and entrenched belief systems. The point requires a brief digression into history.

Medicine and psychiatry From antiquity to the present day, psychiatry has been mainly a practical professional activity dealing with people’s troublesome behaviours, unusual or distressing subjective experiences, or difficulties in relationships, communication, etc. – all within a social and cultural context. It is a simple fact that no other medical discipline evokes, in the average person, such contradictory feelings and images. The stigma attached to mental illness has persisted in every culture, even though today’s societies are in many respects more tolerant or permissive. The controversial social perception of psychiatry is further highlighted by the fact that much of the dissent has come from within the discipline. In the 1960s and ’70s, the most vocal protagonists of the anti-psychiatry movement were psychiatrists and psychologists believing that mental illness, i.e. the subject matter of their profession, did not exist. Why is psychiatry perceived differently from the rest of medicine? The present trend among the majority of mental health professionals – psychiatrists, of course, included – is to adopt and promote the belief that psychiatry is now finally integrated within mainstream medicine, and that both the general public and the rest of the medical profession are ready to embrace a ‘biopsychosocial model’ and to interpret psychiatric disorders as being ‘just like any other disease’. It is debatable whether this ‘normalising’ approach can ever be successful, and whether the conceptual gap between psychiatry and the dominant biomedical model can easily be bridged by the introduction of biomedical technology or by changing the language of psychiatry. Notwithstanding assertions about ‘holistic’ medicine, modern technological medicine remains essentially reductionist (and increasingly so). Although most physicians will admit that mental states influence bodily functions, the psychological dimension of disease tends to be treated as noise in the system, or as a source of troublesome variation in the measurement of biological functions that cannot be accounted for by the ‘objective’ explanatory models available to them.

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On a superficial level, at least, there is much to support such a view of psychiatry and its subject matter. Psychiatric diagnosis and treatment at the end of the 20th century remain as critically dependent on the psychiatrist’s access to the patient’s subjective world, and his or her willingness to share it, as they were a century ago. The professional role of the psychiatrist as a physician is further complicated by the fact that in either the diagnostic setting or the therapeutic relationship, the psychiatrist must possess the skill of using his/her own personality as a clinical instrument for eliciting and interpreting data. This seems to be in the nature of the discipline and its object, and there is no prospect in sight that instrumental measurement will ever supersede the intersubjective core of psychiatric theory and practice. However, the differences between psychiatry and the rest of medicine do not end here. They become even more pronounced at the level of concepts and discourse within the discipline. A telling example is the fact that the theoretical framework of psychiatry has changed little since the turn of the century – reference to concepts formulated in the 19th century, or to the authority of ‘founding fathers’ such as Kraepelin, Bleuler, or Freud, is part of the daily clinical discourse in present-day psychiatry. This inherent historicism of psychiatric discourse is in stark contrast to the positivistic language of other medical disciplines where, by and large, a reference to the views of Laennec or Ossler would be expected from the lecture by the medical historian but hardly from the clinician reasoning about the diagnostic formulation of a case. The peculiar nature of psychiatric discourse is, of course, based on a conceptual continuity with the past which is not much in evidence in other medical disciplines.

Three origins of modern psychiatry Modern psychiatry evolved, at the end of the 18th century and primarily during the 19th century, from three relatively independent strands of ideas and practices. First was asylum psychiatry, associated with the names of reformers such as Pinel, Esquirol, Hill, and Connoly, who conceptualised mental illness as an environmentally influenced and potentially preventable derangement of the mental faculties. For much of the 19th century, contrary to the image that is often conjured, the prevailing view of mental disorder was optimistic and amelioristic, emphasising the possibility of improvement or cure by humane treatment in the sheltered environment of the institution. The second paradigm shift was associated with the birth of what might be called university psychiatry, in the later part of the 19th


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century (Meynert, Wernicke, Kraepelin). The advances in pathology and bacteriology led to the belief that the concepts and methods which had proved successful in understanding infectious disease could be applied to mental disease as well. The study of general paralysis became the prototype of the disease concept in psychiatry, which was an academic invention, and stimulated laboratory brain research and investigations into the hereditary basis of psychiatric illness. University psychiatry, with Griesinger’s dictum that ‘mental diseases are brain diseases’, is thus the precursor of today’s biological psychiatry. The third paradigm was the emergence, from the neurologists’ consulting room, of psychotherapy and psychoanalysis in all their varieties. This focused on patients with less severe but frequent illnesses that often appeared as exaggerations of personality traits or of conflicts of normal mental life. Since neither academic psychiatry nor neurobiology at the time could offer anything specific towards the management of these problems, Freud (himself a neurologist) had to improvise an entirely new kind of psychology – a mixture of astute empirical observations and a self-referential theory of the psyche bordering on mythology. This cursory look at the historic roots of modern psychiatry hints at some of the reasons why it still does not possess a single or unifying conceptual framework. Psychiatry tends to move, pendulumlike, between extreme views on the nature of mental disorders, some of which can have socially harmful or even disastrous consequences. A few examples include: the expansion of mental hospitals and the institutional subculture of psychiatry in the first half of this century; the vulnerability of psychiatry to political pressure and manipulation, as evidenced by the extermination of many thousands of psychiatric patients by the Nazi regime in the name of eugenics; and the notorious cases of compulsory psychiatric treatment for political dissidents in the former Soviet Union. It would be a gross distortion, of course, to portray such aberrations as the essence of psychiatry. But it would be equally erroneous to dismiss them as mere accidents. The conclusion to be drawn is that the scientific concepts about the nature of psychiatric illness – always limited and never complete – can attract ideological and political attention that may be translated into laws, policy, or other action with unforeseen consequences. To quote Eisenberg (1972), “the planets will move as they always have, whether we adopt a geocentric or a heliocentric view of the heavens ... But the behaviour of men is not independent of the theories of human behaviour that men adopt”. A current example is the unplanned aftermath of the deinstitutionalisation movement and of policies which, in many cases, were

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embraced by politicians primarily as a means of cutting down public spending. While in certain countries or areas deinstitutionalisation has worked well and many former patients now lead lives of better quality than before, in other parts of the world the result has been the pauperisation of the mentally ill, a dramatic increase in the number of the homeless and destitute and in the instances in which people with psychiatric disorders become victims of crime, and a doubling or trebling of the suicide rate among people with psychosis in the community.

The new language of ICD–10/DSM–IV and the practice of psychiatry The practice of psychiatry in the clinical setting, in the community, and in the seminar room must face the problems outlined above. Psychiatric diagnosis and classification cannot be decontextualised, and neither ICD–10 nor DSM–IV is entirely free of theoretical assumptions and underlying ideological beliefs. Their use in clinical decision making, in teaching, and in reporting about the nature and magnitude of mental health problems in communities or populations can therefore be expected to have certain side-effects, as well as social and political consequences. Untoward side-effects of the use of tools such as psychiatric classifications can be amplified by certain features of the present Zeitgeist of psychiatry, which is characterised by:

a tendency to reify the concept of disease: the idea that psychiatric ‘disorders’ are discrete entities behaving like medical diseases; the belief in biological reduction, i.e. that the essence of psychiatric disorders will ultimately be explained by neurobiology or genetics; a polarisation between biological and psychosocial approaches, described by Eisenberg (1986) as ‘brainless’ versus ‘mindless’ psychiatry, with little communication between the two; a tendency to medicalise existential and social problems; and a persistence of a ‘theory of mind’ based on notions of 19th century psychology.

Against such a background of ‘prejudice in psychiatry’ (Jaspers, 1963), there are several ways in which the new language of classification could be misinterpreted or misused. First, there is the risk of an uncritical adoption of DSM–IV or ICD–10 as a ‘natural’ system of diseases in psychiatry. Ignoring the fact that the majority of the ‘disorders’


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are of a provisional nature, and that the diagnostic guidelines and criteria represent a practical convention based on consensus, best estimate, and informed judgement, may result in an unwarranted reification of the classification. A second unwanted effect of diagnostic criteria in psychiatric research may be the suppression of interest in exploring variations in the clinical phenomena, in describing atypical forms of a disorder, and in identifying subgroups or new syndromes. Thirdly, the complex relationships between culture and mental disorder may be further obscured. Both ICD–10 and DSM–IV essentially regard culture as a ‘pathoplastic effect’ which distorts the presentation of the disorders as defined in the classification. Although ICD–10 does somewhat better in this respect, having included the views of psychiatrists in developing countries in its formulation, ‘common language’ classifications are generally insensitive to cultural variation and ignore indigenous languages in mental health. Fourthly, the acceptance of a single common language may result in an impoverishment of the psychiatric culture. The use of DSM– IV and ICD–10 may become a matter of political correctness that will influence the decisions and policies of editorial boards of journals, funding agencies, and academic bodies. Finally, and perhaps most importantly, the authority of a common language classification may be turned into a tool for cost control in managed psychiatric care and, hence, into an instrument of social control and the rationing of treatment.

Schizophrenia Perhaps no other example better illustrates the dilemmas arising from the way the classifications are used than schizophrenia research. We shall soon mark the centenary of the concept of schizophrenia. There is no other condition in psychiatry, and probably few in all of medicine, that has been so persistently studied for a comparable length of time. DSM–III and its successors, and now to some extent ICD–10, seem at last to have provided rigorous and widely accepted standards for the diagnosis. As a result, no research grant application stands a chance of being approved, and no journal article of being published, unless the clinical population is described and classified in the terms set forth in DSM–III, –III–R or –IV. Recent clinical and laboratory research has certainly advanced our understanding of the neuropathology, cognitive psychology, neuropharmacology, and possibly epidemiology of schizophrenia. Yet the

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expected major breakthrough has not occurred. After more than 10 years of molecular genetic research, the prospect of finding strong linkage between schizophrenia and definable regions of the genome still seems remote, in spite of the evidence for a genetic contribution to the aetiology provided by family, twin and adoption studies. Although linkage may ultimately be found, it is quite plausible that it will reveal either a number of genes of small effect, or genes linked in only a small proportion of the families. Such a result would call for a re-examination of certain fundamental issues, including the concept and definition of the disorder. Genetic research points to aetiological heterogeneity in schizophrenia. However, we are also facing the problem of clinical heterogeneity. Clinicians today agree that the clinical manifestations of schizophrenia are extremely variable. Unfortunately, one of the implications of this fact – namely, that the extent of heterogeneity calls into question the validity of the established concept of schizophrenia – is rarely acknowledged. Although a number of alternative models have been proposed, including continuum and dimensional schemes, none of them has been particularly successful – partly because they were not properly tested, and partly because of the methodological complexity of non-categorical disease models. Another conclusion is that the acceptance of DSM–III as the ‘gold standard’ of scientific psychiatry has reinforced the unitary categorical concept of schizophrenia precisely at the time when new ways of conceptualising schizophrenia could be initiated and tested. Rather than being used as a set of standardised operational components from which various hypotheses could be assembled, something like an ontological status was attributed to the DSM–III definitions and criteria, ignoring the hypothetical and provisional nature of the construct of schizophrenia (the disease concept of schizophrenia was problematic even to Kraepelin, who virtually abandoned it towards the end of his scientific career (Kraepelin, 1920)). However, contrary to the evidence that the unitary disease concept of schizophrenia is in need of revision, the DSM–III definition has become the principal sampling criterion for recruiting clinical populations for research. As a result, many studies investigate clinical samples which are assumed to be representative of the hypothetical ‘disease’ but are in fact either extremely heterogeneous or otherwise selectively biased. For example, it would make little sense to study the course and outcome of a clinical sample which is selected for chronicity from the start, using the DSM criterion of six-month duration. If there is some truth in this analysis, the need to reappraise the current schizophrenia research strategy is compelling. Two alternatives


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can be considered. The first strategy consists of adopting a purely syndromological approach to the epidemiological and clinical study of the disorders meeting broad criteria for schizophrenia or nonaffective psychosis. The underlying hypothesis to be tested is that the ‘natural’ units of psychopathology corresponding to pathophysiological mechanisms are the individual syndromes or even symptoms. Van Praag (1993) has proposed a shift towards a dimensional or functional orientation in psychopathology and psychopharmacology, in the expectation that ‘functional psychopathology would be to psychiatry what physiology is to medicine’. The second type of strategy is, in a sense, the antithesis of the first. Instead of proceeding from psychopathological symptoms or syndromes to the biological mechanism, it consists of starting from a non-symptom domain by systematically exploring neurophysiological, cognitive, and possibly neurochemical variables for which there is prima facie evidence of an increased incidence in individuals with schizophrenia and in their biological relatives, as compared with the general population. For example, the study of basic neurocognitive abnormalities across different diagnostic groups (including first-degree relatives of patients) and in general population samples may reveal unexpected patterns of association with clinically significant symptoms, behaviour, or personality traits that would make them better phenotypes for genetic linkage research than the present diagnostic categories. It is quite possible that such extended phenotypes would exhibit clearer transmission patterns than symptomatically defined schizophrenia.

Biological–psychosocial split? The diagnosis and classification of psychiatric disorders today presents a mixture of successes and contradictions which mirror the inconsistent conceptual basis of the discipline itself. A point of view expressed increasingly often is that psychiatry will gradually dissolve as a single discipline. Applied or clinical neuroscience will make the study of psychopathology and of the subjective experience of persons with mental disorders superfluous. For example, knowledge about the biological causes of schizophrenia will redefine psychopathology as an epiphenomenon that is relatively unimportant from a medical point of view (although it may continue to represent an anthropological interest). This position corresponds precisely to what Jaspers (1963) termed ‘the somatic prejudice’ in psychiatry – the belief ‘that all psychological interest in schizophrenia will vanish once the morbid somatic process

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that underlies it is discovered’. Undoubtedly, research using diagnostic concepts, classification models, and methods of neuroscience is of paramount importance to any progress in unravelling the causes and mechanisms of psychiatric disorders. However, the representation of reality gained with such tools is a mere abstraction from the much richer and immediate reality of daily life and everyday consciousness, Husserl’s Lebenswelt (Husserl, 1964), which is the very subject matter of psychopathology. The conclusion is that psychiatry (and, within it, psychiatric diagnosis and classification) needs to rediscover the reality of this Lebenswelt, possibly at the cost of changing some of its concepts, language and technology over the coming decades.

References EISENBERG, L. (1972) The human nature of human nature. Science, 176, 123–128. —— (1986) Mindlessness and brainlessness in psychiatry. British Journal of Psychiatry, 148, 497–508. G UZE , S. (1989) Biological psychiatry: is there any other kind? Psychological Medicine, 19, 315–323. HUSSERL , E. (1964) The Idea of Phenomenology. The Hague: Martinus Nijhoff. JASPERS, K. (1963) General Psychopathology. Manchester: Manchester University Press. K RAEPELIN , E. (1920) Die Erscheinungsformen des Irreseins. Zeitschrift für die gesamte Neurologie und Psychiatrie, 62, 1–29. S TRÖMGREN , E. (1982) In Psychiatrists on Psychiatry (ed. M. Shepherd), pp. 152–169. Cambridge: Cambridge University Press. VAN P RAAG , H. M. (1993) Make-believes in Psychiatry or the Perils of Progress. New York: Brunner/ Mazel.

Mental health information transfer

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WHO’s contribution to mental health information transfer SIR DAVID P. GOLDBERG

Introduction In the past 25 years a flood of information about mental disorders has been sent round the world from Geneva by a dedicated and cohesive team led by Norman Sartorius. Wherever one goes in the world, many have met him, most have read him, and everyone has heard of him. He is fluent in many languages, and he has even been heard to lecture in a language he claims not to be able to speak. For psychiatrists everywhere, he has been the personification of WHO. Information is transferred round the world by the printed word, by television, and by computer. It is also transferred inside people’s heads – this is perhaps the most important way, even if it is evanescent. And it is the means nearest to Dr Sartorius’s heart.

Information transfer by computer Transfer of information by television and computer can be dealt with quite quickly. A recent international study on mental disorders in general medical settings (Ustun & Sartorius, 1995) has considerably speeded up old methods of collaboration between participating countries by using computer-administered scoring procedures. Each centre received a data entry disc and entered their data themselves. Discs were sent to Geneva, where they were checked and collated by headquarters’ staff. The arrival of Bedirhan Ustun has greatly helped to modernise WHO’s procedures in this respect. We expect that the primary care version of ICD–10 will be made available to GPs in a 57

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computerised form, accessible to those who now routinely use desktop computers and the Windows operating environment as an aid to consultation. Gavin Andrews’s unit in Sydney has now produced both a computerised diagnostic aid for the consulting room, which is loaded into a standard Windows program, as well as a computerised version of the Composite International Diagnostic Interview (CIDI).

Information transfer by television WHO has used television to test inter-rater reliability for many years. It has recently added two new approaches: providing training on standardised interview procedures, and providing instructional videotapes for working clinicians. The WHO study on psychological disorders in general medical settings provides a videotape with the briefing pack sent to participating centres. One example of the research use of television is a demonstration tape of a research interview, during which a voice-over of a teacher explains the finer points of the rating procedures, with computergenerated graphics showing how the ratings work. Dr Sartorius has greatly encouraged this use of television, which is particularly suitable for making researchers aware of the workings of complex rating scales like that employed by the CIDI.This is followed by a demonstration tape accompanied by criterion ratings, which can be used in participating centres to test new raters using the interview. These tapes are distributed by WHO in Geneva, and allow local workers who may not have been able to attend an international meeting to participate in procedures more thoroughly than would have been possible previously. Another recent videotape demonstrates use of the version of ICD– 10 designed for primary care physicians. WHO has also supported the production of instructional videotapes for medical officers in developing countries. Some years ago, Dr Sartorius asked whether it would be possible to bring eminent teachers from the Third World together with European teachers who were skilled in making instructional tapes of high technical quality. He emphasised that it was important for medical officers in developing countries to be taught by local experts who were familiar with problems in their culture, by means of tapes featuring local people being interviewed by local doctors. The interviews between these doctors and their patients are sometimes in English, and sometimes in a local language. In the latter case, the videotapes provide English subtitles. The tapes have been a huge success in the countries in which they were made. Topics now include depression, psychosis, psychotherapy for primary care practitioners, the persistent complainer, and the detection of disorder.


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It is possible to provide subtitles in other languages. For example, a tape on depression made in Pakistan by Professor Malik Mubbashar on depressive illness was successfully used in China by super-imposing Chinese subtitles. There was really no need to use English subtitles for the doctor, who was talking to the patient in Urdu, although the teacher’s voice was still heard in English. Other TV-based materials from WHO accompany instructional materials on insomnia or depression in general practice, by various authors in both French and English. A recent Indian film deals with epilepsy.

Information transfer by the printed word I shall not provide a list of the flood of books, papers in refereed journals and special publications that have emerged from the Division of Mental Health. Other chapters (Chapter 2 and 5) cover the role of the division in producing taxonomies and research interviews, but some mention must be made of the avalanche of scientific papers that has emerged from the research programme initiated by WHO. In number they would do credit to a full-time research institute. Their quality has earned them a place in the world’s best journals, and they have brought research skills to places where no mental health research had ever been carried out. We now know that the major forms of mental disorders occur throughout the world, and we have meticulous descriptions of the variations in phenomena across various cultures. The decade of research activity described by Dr Sartorius in 1989 included 103 publications from his division, only 14 of which list him as first author; prominence is given to the many colleagues world-wide who have contributed to the work (Sartorius, 1989). He has enabled others to do things that they did not know they were capable of before they were encouraged by him. He is also a great editor, and has produced numerous books describing international initiatives, collaborative research and international conferences and seminars. It would be tedious to take you through this mountain of print, but perhaps permissible to pick out some of the more unusual achievements. Achievements in primary care Training health staff to deliver care for mental disorders in primary care settings has been one of the crowning achievements of the Division of Mental Health. Countless people with mental disorders – certainly

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hundreds of thousands, perhaps millions – who would have received no care whatsoever have now received care. The programme has involved the preparation of training manuals for both medical officers and multi-purpose care workers in developing countries. The work began with the WHO Collaborative Study on Strategies for Extending Mental Health Care, described by Harding and others in 1980. This study reports a research project: but it was one which was to have far-reaching consequences. The investigators found a high prevalence of mental disorders in four developing countries, but found that most of these were untreated. Rather than argue for improved detection, they stressed the need for better training on management, and the involvement of multi-purpose health workers in mental health care. There are now so many training manuals for use in developing countries that WHO had to have a directory of them (WHO, 1992). Eighty-two different manuals were listed at the time the directory first appeared. They are in 19 languages and deal with the entire range of commonly encountered problems, as well as the skills needed to deal with them. There are manuals for Medical Officers, as well as those for paraprofessional staff. It is likely that these publications have done the world more good than many of the more apparently deserving academic publications. Other printed aids to mental health work in primary care are diagnostic flow charts, first produced for WHO by Essex & Gosling (1983). Meusing & Wankiri (1988) describe how these can be used by general nurses without previous mental health training, resulting in correct decisions 84% of the time. The development of ICD–10 has been described in Chapter 2, but the primary care version of this classification (ICD–10–PHC) is another memorable example of the use of the printed word. This is now available in several forms, and may be adapted for local use in particular countries. The basic features are that it is confined to those mental disorders that are common in primary care settings, and contains detailed advice on management of the various disorders – rather than merely being concerned with diagnosis. In its most usual form, each disorder is shown as a double spread when the appropriate page is opened – with presenting symptoms and differential diagnosis on the left side of the page, and advice on information to be given to the patient and his or her family, psychological treatments, drug treatments and indications for specialist referral on the right (Ustun et al, 1995). In its most recent version in England, for example, the classification has been discussed in detail with local general practitioners,


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who have asked for additional disorders, have agreed the precise indications for specialist referral in meetings with their local psychiatrists, and have added information about local voluntary organisations and self-help groups which offer assistance to those with particular disorders. In addition to the 24 conditions covered by the basic classification, for example, they have requested advice on bereavement, deliberate self-harm and chronic severe anxious depression. In this way the classification is ‘owned’ by local primary care staff, resulting in more regular use of the system. The WHO study of ‘Mental Illness in General Health Care’ was perhaps the most ambitious study ever undertaken of psychological disorders in primary care settings. The study was carried out simultaneously in 14 cities across the world, using the same instruments. Over 26 000 people, speaking 11 different languages, were screened in the first stage of the study, and detailed research interviews were carried out in a stratified sample of approximately 400 patients in each centre. The patients were followed up at three months and one year, producing a wealth of data about the different forms that mental disorders take, the disability associated with each kind, and the longitudinal course of the disorders (Ustun & Sartorius, 1995). This study has now resulted in well over 50 papers, dealing with every aspect of mental disorders that is encountered in these settings. It is unlikely to be bettered for many years. Consensus statements Consensus statements, once they are agreed upon, are another form taken by the printed word. Consensus statements promoted by WHO are available on the treatment of depression, and on the use of anticholinergics in the treatment of psychosis.

Information transfer inside people’s heads Formidable quantities of information travel round the world in Dr Sartorius’s head. Like the flying Dutchman, he seems condemned to perpetual motion round the world – but in his case, carrying the message of WHO. It seems unlikely that his retirement from WHO will make much difference here. At the time he stepped down, WHO had active links with centres in more than 60 countries, and had organised numerous national workshops attended not only by health workers but by those in social welfare and education. Participants at these workshops present epidemiological studies carried out under the aegis of WHO,

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and learn more about the public health approach to problems posed by mental disorders (Sartorius, 1993). One must also remember that no meeting of the World Psychiatric Association is complete without sessions devoted to work sponsored by WHO, and that members of the Division of Mental Health regularly attend major national psychiatric conferences and spread WHO’s message. However, information also travels round the world in other people’s heads. There are two major groups here. The first consists of experts attending meetings in Geneva, who advise WHO on their particular area, and then go home with a clearer idea of what WHO has achieved. The second is made up of those still in training. WHO Collaborating Centres carry out a great deal of research and training in their own countries (see elsewhere in this volume). WHO has organised some 55 training fellowships in the field of psychiatry, neurology and mental disorders. They cover a wide range of topics, from basic neuroscience to clinical research and clinical training, and cover the developed world of North America, Europe and Australia. Candidates are advised on how to obtain sponsorship, and how to set about making their applications. Dr Orley and Dr Sartorius encouraged me and my colleagues to set up an entirely new sort of training course, for doctors from the developing world living in Manchester, England. Doctors from Africa and the Indian subcontinent who express the wish to return to their countries are offered specialised clinical training, as well as advice on how to develop mental health services, plan training courses for others, and evaluate what they have done. The training that they receive is a very far cry from that received by a previous generation of foreign visitors who came to Europe, cap in hand, to learn how psychiatry was practised in our countries. If we had not been steered so firmly by Drs Orley and Sartorius, we might have treated them in the old way too. Each of our students carries out a project concerned with a change they will try to make in their own mental health service when they return. In 1993, for example, all of them planned training courses for multi-purpose care workers, with each student taking a different topic. Our most spectacular success came when one of our students chose to write a national plan for mental health for his country. This topic was suggested because contacts at WHO had indicated that his government did not have such a plan. The one he wrote, sitting in isolation in a Preston mental hospital, impressed us so much that it was sent to Dr Sartorius. He agreed that it was excellent, and we awarded it our first WHO prize. On his return, our student was asked to join his government’s Ministry of Health, as others clearly shared our high opinion of what he had done.


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We are profoundly grateful to John Orley, without whose unfailing assistance and good counsel we could never have voyaged into such unfamiliar territory, at so much gain not merely to our students, but to ourselves as well. This was probably the most interesting and rewarding activity we jointly undertook, and we are confident that our network of students will remain in contact with us for many years. However, there is no cause for complacency. The increasing cost of training in developed countries has meant that fewer psychiatrists from developing countries can avail themselves of a training experience abroad before returning home. Training posts that could be used to benefit the developing world are given to doctors from developing countries who wish to use them as stepping stones to career positions elsewhere. For example, it has been estimated that there are fewer than 100 trained psychiatrists in Pakistan, but more than 700 Pakistani psychiatrists in the USA and the UK. In 1989, WHO sponsored a document that considered the need for postgraduate training in psychiatry in the developing world, and offered a 12-point ‘Call for Action’. This points out the need for greater flexibility in planning training events, with some provided in the trainee’s own country, but supplemental initiatives offered in countries foreign to the trainee. The report emphasises the importance of training in teaching and research methodology, and suggests that WHO continues to use its own funding wisely to facilitate international exchanges. The past 25 years have seen the inauguration of a mental health programme that has been of immense benefit to the developing world and has brought psychiatrists together from numerous countries. Although Dr Sartorius will be a hard act to follow, one hopes that WHO will continue to provide strong support to one of its most successful divisions.

References ESSEX , B. & G OSLING , H. (1983) An algorithmic method for management of mental health problems in developing countries. British Journal of Psychiatry, 143, 451–459. HARDING , T. W., DE A RANGO , M. V., B ALTAZAR , J., et al (1980) Mental Disorders in Primary Care: a study of their frequency and diagnosis in four developing countries. Psychological Medicine, 10, 231–241 M EUSING , K. & W ANKIIRI , V. (1988) Use of flow-charts by nurses dealing with mental patients: an evaluation in Lesotho. Bulletin of the World Health Organization, 66, 507– 514. SARTORIUS , N. (1989) Recent research activities in the WHO’s mental health programme. Psychological Medicine, 19, 233–244. —— (1993) WHO’s work on the epidemiology of mental disorders. Social Psychiatry and Psychiatric Epidemiology, 28, 239–242.

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USTUN , B., G OLDBERG , D., C OOPER , J., et al (1995) New classification for mental disorders with management guidelines for use in primary care: ICD–10 PHC, Chapter 5. British Journal of General Practice, 45, 211–215. —— & S ARTORIUS , N. (eds) (1995) Mental Disorders in General Health Care. Chichester: John Wiley & Sons. WHO (1992) Directory of Training Packages. Geneva: World Health Organization.

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Assessment instruments developed in the framework of WHO’s mental health programme ALEKSANDAR JANCA and CHARLES PULL

Introduction In order to improve diagnostic precision in psychiatry, uniformity and reliability of data within studies, and consistency and comparability of data across studies, a number of assessment instruments have been developed in the framework of WHO’s Mental Health Programme. Many of these instruments have been extensively tested for their feasibility and cross-cultural applicability in more than 60 countries, representing distinct cultures and different schools of psychiatry and psychiatric traditions, and then released by WHO for general use. This chapter provides descriptions of the main assessment instruments developed for or used in studies and projects coordinated over the years by WHO’s Division of Mental Health and Prevention of Substance Abuse. Only basic features of the WHO assessment instruments released for general use are given here. More detailed information about the development, characteristics and field-test results of these and many other WHO assessment instruments, including sample pages and summary tables, can be found in the Catalogue of WHO Psychiatric Assessment Instruments (Janca & Chandrashekhar, 1995) and elsewhere (Janca et al, 1994; Sartorius & Janca, 1996). The catalogue is available from WHO on request.

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Alcohol Use Identification Test (AUDIT) AUDIT (Babor et al, 1989) is a brief interviewer-administered or selfreporting instrument intended for use in primary health care settings to identify people whose alcohol consumption has become hazardous or harmful to their health. The instrument contains 10 questions related to the amount and frequency of drinking, drinking behaviour, and problems or adverse psychological reactions due to alcohol use. Questions in the AUDIT are coded from 0 to 4 and a score of 8 or more identifies a positive case. If the respondent is defensive or uncooperative, the Clinical Screening Procedure (CSP) – a listing of indirect questions and clinical signs likely to indicate the harmful use of alcohol – can be employed. It takes about two minutes to administer AUDIT or CSP. AUDIT was used in the WHO Collaborative Project on the Identification and Treatment of Persons with Harmful Alcohol Consumption, and found to be a reliable and valid tool for detecting harmful alcohol consumption and distinguishing between light drinkers and those with hazardous or harmful use of alcohol (Saunders & Aasland, 1987; Saunders et al, 1993). AUDIT is available in English, Japanese, Norwegian, Romanian and Spanish.

Child Care Facility Schedule (CCFS) The CCFS (WHO, 1990) is an 80-item observer rating schedule designed for the assessment of the quality of care in day-care programmes for children. The instrument covers the following eight areas that define quality child care: physical environment, health and safety, nutrition and food service, administration, staff–family interaction, staff–children interaction, observable child behaviour, and curriculum. The instrument is accompanied by a glossary which defines each of the items to be rated. A user manual including a list of references relevant to the CCFS is also available. The CCFS was tested in Greece, the Philippines and Nigeria and found to be cross-culturally acceptable and reliable for the assessment of various types of child care facilities in different parts of the world (Tsiantis et al, 1991).

Cognitive/Neuropsychological Assessment Schedule This instrument is designed for the comprehensive assessment of cognitive functioning and consists of about 70 questions related to the patient’s orientation, memory, reading, writing, general knowledge

Assessment instruments 67 and comprehension. The questions are grouped into the following sections: brief summary of cognitive functioning; comprehensive assessment of cognitive functions; rating scale of daily living activities, ranging from above average functioning to severely reduced functioning. The instrument is intended for use by psychiatrists or psychologists and it takes about 45 minutes to administer. The instrument was developed for WHO’s Cross-cultural Study on Neuropsychiatric Aspects of Infection with the Human Immunodeficiency Virus I, which was carried out in six countries in the industrialised and developing parts of the world (Maj et al, 1993, 1994).

Composite International Diagnostic Interview (CIDI) CIDI (WHO, 1993) is a highly structured interview schedule designed for use by trained lay interviewers and in epidemiological studies of mental disorders across cultures. The most recent version of the instrument (CIDI 2.0) assesses the following diagnoses according to ICD–10 (WHO, 1992) and DSM–IV (American Psychiatric Association, 1994) criteria: somatoform disorders dissociative disorders phobic disorders other anxiety disorders post-traumatic stress disorder depressive disorders dysthymia mania bipolar affective disorder schizophrenia other psychotic disorders eating disorders obsessive–compulsive disorder substance use disorders organic mental disorders sexual dysfunctions. CIDI questions are fully spelled out and positive answers are further explored with a specified probing system, which aims at assessing the psychiatric significance and clinical relevance of a reported phenomenon. CIDI also incorporates questions for the assessment of the first and last occurrence of a symptom (onset and recency questions) and questions necessary for determining the duration and frequency of selected symptoms and syndromes.

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The CIDI schedule comes with a set of manuals, and a computer program that enables users to enter, clear and score the interview. Proper training is necessary before using CIDI, and can be obtained through a network of CIDI training and reference centres located in Amsterdam, Beijing, Luxembourg, Milan, Munich, San Juan, St. Louis, Sao Paulo and Sydney (see the Appendix to this chapter). CIDI exists in a number of versions and modules. These include: (a) Computerised CIDI (CIDI Auto): a software version of the instrument which can be used on any IBM-compatible computer with hard disk. CIDI Auto offers several advantages to the user: simplified probing of positive answers, which enhances the reliability of scoring; shorter administration time; and automatic entry, scoring and storage of data. The users’ guide provides information on the installation and use of the programme. (b) Quick CIDI: a computerised version of CIDI that shortens the interview by checking each answer against the respective diagnostic criterion and skipping to the next diagnosis if the required criterion is not met. It is also possible to shorten the interview by choosing the diagnoses or diagnostic systems of interest (i.e. ICD or DSM). (c) CIDI Primary Health Care Version (CIDI–PHC) is a modified CIDI designed for use by primary care workers. The instrument uses a simplified probing system and covers diagnoses commonly encountered in primary care and general health care settings (e.g. anxiety disorders, depression, and somatoform disorders). (d) The University of Michigan Version of CIDI (CIDI–UM) is a version of the CIDI modified for the US National Comorbidity Survey. The instrument includes commitment and motivation probes for recall of lifetime episodes, and clarifying probes for CIDI questions found in the pilot testing to be unclear or confusing to the respondents. CIDI–UM does not contain a section on somatoform disorders or a minimental state examination. A section on antisocial personality disorder has been added to the instrument. (e) CIDI Substance Abuse Module (CIDI–SAM) is a short version of the CIDI which covers only substance use disorders. It includes a number of additional questions to elicit onset and recency of each symptom, as well as the physical, social and psychological consequences of substance misuse. (f) CIDI Post-traumatic Stress Disorder Module (CIDI–PTSD) is an instrument designed for the assessment of stressful events

Assessment instruments 69 and their psychological consequences. The respondent is asked to describe up to three stressful events in order of their severity; each of them is then explored further according to specified ICD–10 and DSM–IV criteria for PTSD. (g) Somatoform Disorders Schedule (SDS) is a CIDI-based instrument intended for the assessment of somatoform disorders and neurasthenia according to ICD–10 and DSM– IV criteria. Several culture-specific symptoms of somatoform disorders have been added, as well as a section on disability and care-seeking behaviour.

WHO Psychiatric Disability Assessment Schedule (WHO/DAS) WHO/DAS (WHO, 1988) is a semi-structured instrument for the assessment of the social functioning of patients with mental disorders. It consists of five sections, each of which covers various aspects of the patient’s social functioning (self-care, marital role, parental role, occupational role, functioning in the hospital, etc.). WHO/DAS items are rated on a 6-point scale ranging from no dysfunction to maximum dysfunction. The patient’s functioning is to be rated against the presumed ‘average’ or ‘normal’ functioning of a person of the same gender, comparable age and similar socio-economic background. The instrument can be administered by psychiatrists, psychologists or social workers and its average administration time is 30 minutes. The instrument is available in the following languages: Arabic, Bulgarian, Chinese, Croatian, Danish, English, French, German, Hindi, Japanese, Russian, Serbian, Spanish, Turkish and Urdu. WHO/DAS was tested and used in the WHO Collaborative Study on the Assessment and Reduction of Psychiatric Disability (Jablensky et al, 1980), and in many other international and national projects worldwide. A short version of WHO/DAS (WHO DAS-S; Janca et al, 1996b) is also available. It has been produced as a companion to Axis II (Disabilities) of the ICD–10 multi-axial system for use in adult psychiatry. The WHO DAS–S covers four specific areas of the patient’s functioning:

personal care occupation family and household broader social context.

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The instrument takes about five minutes to administer if the clinician knows the patient and has examined him or her previously.

ICD-10 Symptom Checklist for Mental Disorders This is a semi-structured instrument designed as a guide for psychiatrists and clinical psychologists in their examination of psychiatric patients. The clinician must examine the patient, phrase the necessary symptom questions, and assess theclinical significance of the positive answers as in a routine clinical interview. The checklist provides lists of the main psychiatric symptoms and syndromes in the FO to F6 categories of ICD–10. Symptoms are grouped into the following sections:

organic and psychoactive substance use syndromes (F0/F1 module) psychotic and affective syndromes (F2/F3 module) neurotic and behavioural syndromes (F4/F5 module) personality disorders (F6 module).

In addition to a listing of the symptoms, the modules contain items for recording onset, severity and duration of the syndrome as well as number of episodes (where applicable). To help the clinician in making differential diagnoses, the modules also list symptoms and states which, according to ICD–10 criteria, should be excluded or else associated with the syndrome (Janca et al, 1993; Janca & Hiller, 1996). Administering the checklist takes about 15 minutes. No specific training is required for an experienced clinician. The instrument is available in Chinese, English, Estonian, French, German, Italian, Japanese, Kannada (India), Portuguese, Russian and Spanish. It comes with the ICD–10 Symptom Glossary (Isaac et al, 1994), which provides brief definitions of the symptoms and syndromes covered by the instrument. The F4 module of the checklist exists in an expanded form, the Somatoform Disorders Symptom Checklist, which covers symptoms of ICD–10 somatoform disorders and neurasthenia. It also operationalises ICD–10 criteria for somatoform disorders and contains a simple algorithm enabling clinicians to score specific diagnostic categories of somatoform disorders according to ICD–10.


International Personality Disorder Examination (IPDE) The IPDE is a semi-structured diagnostic interview schedule designed for the assessment of phenomenology and life experiences related to the diagnosis of personality disorders according to ICD–10 and DSM– IV criteria. The instrument is intended for use by psychiatrists and clinical psychologists after training. Due to its long administration time (two to three hours), it has been produced in two versions, one for ICD–10 and one for DSM–IV criteria. The IPDE items are arranged under the following six headings:

work self interpersonal relationships affects reality testing impulse control.

The items are introduced by open-ended inquiries and followed by additional questions, which give the individual the chance to discuss the specific experience and to elaborate with examples and anecdotes. Both versions of the IPDE come with instruction manuals, handscoring sheets, computer scoring programs and self-administering screening inventories. The ICD–10 version of the instrument has been published together with a monograph describing the development and field trials of the instrument (Loranger et al, 1997). The IPDE is available in the following languages: Dutch, English, Estonian, French, German, Hindi, Italian, Japanese, Kannada (India), Norwegian, Swahili and Tamil. IPDE training is offered in Bangalore, Luxembourg, Tokyo and White Plains (see Appendix to this chapter).

Life Events Schedule (LES) The LES is a semi-structured interview schedule designed for use by health or research workers in collecting and recording data on important life events of the patient. The instrument provides a set of criteria for determining whether specific occurrences are to be defined as life events and instructions for rating the specific characteristics of life events, including their relationship to the patient’s illness.

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Part I of the instrument contains items grouped into the following areas: personal; livelihood; family/household; and social network. Additional items are classified under headings such as positive and negative goal fulfilments; forecast of future changes; surprising news/ revelations; etc. The investigator is required to collect information necessary for a narrative description of each life event and to estimate its date of occurrence and relationship to the patient’s disorder. Part II has to be completed outside an interview situation from the data collected in Part I. It results in a chronological narrative account of life events occurring in the relevant period. The objective impact of each event is coded from mild (no impact) to severe (marked impact). Relationship to illness is coded as independent, possibly independent and probably illness-related. The LES manual facilitates the use of the instrument and provides rating instructions. Average administration time is 120 minutes, and the instrument is available in English, Kannada (India), Spanish and Yoruba.

Pathways Interview Schedule This is a semi-structured instrument for the systematic collection of information on the routes and sources of care used by the person before seeing a mental health professional. The average administration time of the instrument is 10 minutes and it can be used by any mental health professional. The instrument consists of seven sections, which cover the following: basic information about the centre, mental health professional and person; details of the first, second, third and fourth carers; and description of the main problem, main treatment offered and duration of the patient’s journey to each of the carers. An instruction manual is available. The English version of the instrument has been translated into Arabic, Bahasa (Indonesia), Chinese, Czech, French, Japanese, Kannada (India), Portuguese, Spanish, Turkish and Urdu (Pakistan).

Present State Examination (PSE) The PSE (Wing et al, 1974) is a guide to structuring a clinical interview of the psychiatric patient. It helps in assessing present mental state and in getting a descriptive account of symptoms during the past month. A glossary containing definitions of symptoms comes along with the instrument.

Assessment instruments 73 There are 140 items to be rated in the PSE and the ratings are precoded. Information obtained from case notes and informants may be used to probe the patient’s answers, but not to rate the symptoms. If necessary, the PSE can be administered in two or three stages. The PSE comes with a computer program (CATEGO) which links the symptoms to the diagnostic classification system. The instrument can be administered by a clinician (psychiatrist or clinical psychologist) after appropriate training. The average administration time of the PSE is 45 minutes. English, French and German versions of the instrument are available. There are nine earlier editions of the PSE. Its tenth edition represents the core of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), which is described later.

WHO Psychological Impairments Rating Schedule (WHO/PIRS) WHO/PIRS is a semi-structured clinical interview schedule for the assessment of selected areas of psychological and behavioural deficits in people with functional psychiatric disorders. The instrument covers the following areas: activity withdrawal social skills and communication global impression of the person’s personality. The instrument includes a pattern assembly, three Rorschach cards, and a letter-deletion test. The tools are aimed at assessing the patient’s performance when presented with standard tasks. WHO/PIRS can be administered by psychiatrists or clinical psychologists after appropriate training. If the administration of WHO/PIRS follows a PSE interview, the average administration time is about five minutes. The instrument exists in Arabic, Bulgarian, Croatian, English, French, German, Serbian and Turkish. Reliability of the WHO/PIRS was tested and found to be good (kappa 0.79) in the WHO Collaborative Study on Impairments and Disabilities Associated with Schizophrenic Disorders (Jablensky et al, 1980).

Schedules for Clinical Assessment of Acute Psychotic States (SCAAPS) SCAAPS is a semi-structured instrument for collecting information about people with acute psychotic states. The information is based

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on a clinical interview of the patient, medical records and key informants. The instrument can also be used for recording the followup diagnostic evaluation of the person. SCAAPS consists of the following parts:

screening criteria for psychotic states (Part A) items related to psychiatric history and social description of the patient (Part B) a checklist of symptoms ranging from worrying and anxiety to symptoms reflecting stressful life events (Part C) initial diagnostic evaluation and one-year follow-up diagnostic evaluation (Part D) treatment, course and outcome (Part E) narrative summaries of initial and follow-up examinations of the patient.

SCAAPS is intended for use by psychiatrists and its average administration time is 60 minutes. Czech, Danish, English, Hindi and Yoruba (Nigeria) versions are available. The instrument was used in the WHO Collaborative Studies on Acute Psychosis and was found to be cross-culturally applicable and reliable (Cooper et al, 1990).

Schedules for Clinical Assessment in Neuropsychiatry (SCAN) SCAN (Wing et al, 1990; WHO, 1994) is a set of instruments aimed at assessing, measuring and classifying the psychopathology and behaviour associated with the major psychiatric disorders of adult life. The instrument has a semi-structured format and offers considerable freedom for interviewers to phrase questions about symptoms. However, the clinical relevance of the symptoms should be assessed on the basis of the definitions provided in the SCAN Glossary. SCAN consists of the following components: (a) the 10th edition of the Present State Examination (see above); (b) Glossary of Differential Definitions; and (c) Item Group Checklist and Clinical History Schedule. The SCAN Interview Schedule has two parts. Part I covers nonpsychotic phenomena and includes sections on physical health, worrying, tension, panic, anxiety and phobias, obsessional symptoms, depressed mood and ideation, impaired thinking, concentration, energy, interests, bodily functions, weight, sleep, eating disorders and alcohol and drug misuse. Part II is intended for the assessment of psychotic and cognitive disorders and abnormalities of behaviour, speech and affect.

Assessment instruments 75 The instrument can be used by psychiatrists or clinical psychologists after appropriate training. In using SCAN, the interviewer decides whether a symptom has been present during the specified time and to what degree of severity. The assessed periods usually include the month before examination (i.e. ‘present state’) and any time prior to it (i.e. ‘lifetime before’). A ‘representative episode’, if particularly characteristic of the person’s illness, can also be chosen. SCAN comes with a computer program that scores diagnoses according to ICD–10 and DSM–IV criteria. A computerised version of SCAN, called CAPSE (computer-assisted PSE), is also available. It assists the interviewer in applying SCAN and allows direct entry of ratings at the time of the interview. The programme displays SCAN questions, ratings and glossary definitions in different windows on the screen and shows the path of questions already asked and rated. SCAN exists in the following languages: Chinese, Danish, Dutch, English, French, German, Greek, Italian, Kannada (India), Portuguese, Spanish, Turkish and Yoruba (Nigeria). SCAN training and reference centres are located in Australia (Perth), China (Beijing), Denmark (Aarhus), Germany (Lübeck and Mannheim), Greece (Athens), Japan (Nagasaki), India (Bangalore), Luxembourg, The Netherlands (Groningen), Spain (Santander), Turkey (Ankara), the UK (Leicester, London and Nottingham), and the USA (Baltimore, MD, Farmington, CT and St. Louis, MO) (see Appendix).

Self-Reporting Questionnaire (SRQ) The SRQ is a screening instrument for the assessment of patients in primary care settings. It serves to increase primary care workers’ awareness that psychological symptoms are a major problem in these settings. The instrument can be self- or interviewer-administered and takes 5–10 minutes. The full version of SRQ contains 24 questions, 20 covering neurotic symptoms and four psychotic symptoms. Questions are scored 1 (present) or 0 (absent) and a score of 7 or above indicates the probable presence of a psychological problem. The SRQ comes with a user’s guide (Beusenberg & Orley, 1994) which provides a description of the instrument, instructions for its use and scoring, and reliability and validity results. An extensive list of references related to the SRQ is also included. The SRQ has been translated into the following languages: Amharic (Ethiopia and Eritrea), Arabic, Bahasa (Malaysia), Bengali, English, French, Hindi, Italian, Kiswahili, Portuguese, Spanish and Tagalog (Philippines).

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The SRQ was used in the WHO Collaborative Study on Strategies for Extending Mental Health Care and the WHO Study on Mental Disorders in Primary Health Care, and found to be a reliable tool for use in different countries and cultures (Harding et al, 1980, 1983).

Standardised Assessment of Depressive Disorders (SADD) SADD is a standardised and comprehensive instrument intended for the assessment of symptoms and signs of depressive disorders. It can be administered by psychiatrists after appropriate training and its average administration time is one hour. Part I of the instrument covers basic identifying data (person’s name, age, gender, residence, etc.). Part II, in the form of a checklist, covers symptoms, signs and history of depressive illness and provides possible probes and examples for each item. A number of open-ended questions for recording the culture-specific symptoms of depression are also included in the checklist, as are items related to the past history of the person. Part III of the instrument serves to record the diagnosis and severity of the person’s condition. The ratings in SADD refer to the week preceding the interview or to any other period prior to the current episode of illness. The instrument is available in Bulgarian, Farsi, French, German, Hindi, Japanese, Polish and Turkish.

Conclusions Training in and use of the instruments described in this paper are facilitated by a network of WHO collaborating centres and training and reference centres. To enhance communication among users of WHO instruments, a series of newsletters, catalogues and other documents have been regularly issued by WHO. WHO instruments are being periodically updated to incorporate new knowledge and experience obtained from users. In this task WHO receives valuable advice from several editorial and advisory groups specialised in the development and testing of WHO instruments. In order to assist users in the translation of WHO instruments, WHO has produced a set of translation guidelines offering step-by-step procedures for producing equivalent versions of WHO instruments in different languages. Many WHO instruments have been tested for their feasibility and reliability in different cultures and settings. The cross-cultural

Assessment instruments 77 applicability of WHO instruments was also explored in a WHO project which developed a number of qualitative and quantitative research methods suitable for testing psychometric properties of WHO instruments across cultures (Room et al, 1996). Development of a ‘common language’ for world-wide use by various types of mental health professionals has been one of the major goals of WHO’s Mental Health Programme. WHO assessment instruments that have been developed, tested and used in different cultures have substantially contributed to the development of such a language and it is hoped that the number of users will grow, thus fostering a better understanding and collaboration among mental health professionals the world over.

References A MERICAN P SYCHIATRIC A SSOCIATION (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn). Washington, DC: American Psychiatric Association. BABOR , T. F., DE LA F UENTE , J. R., S AUNDERS , J. B., et al (1989) AUDIT, the Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Health Care. Geneva: World Health Organization. BEUSENBERG, M. & ORLEY, J. (1994) A User’s Guide to the Self-Reporting Questionnaire (SRQ). Geneva: World Health Organization. COOPER, J. E., JABLENSKY, A. & SARTORIUS, N. (1990) WHO collaborative studies on acute psychoses using the SCAAPS schedule. In Psychiatry: a World Perspective. Vol. 1: Classification and Psychopathology, Child Psychiatry, Substance Use (eds C.N. Stefanis, et al), pp. 185–192. International Congress Series 900. Amsterdam: Excerpta Medica. HARDING , T. W., DE A RANGO , M. V., B ALTHAZAR , J., et al (1980) Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychological Medicine, 10, 231–241. ——, C LIMENT , C. E., D IOP , M., et al (1983) The WHO collaborative study on strategies for extending mental health care. II: the development of new research methods. American Journal of Psychiatry, 140, 1474–1480. ISAAC , M., J ANCA , A. & S ARTORIUS , N. (1994) The ICD-10 Symptom Glossary for Mental Disorders. Geneva: World Health Organization. JABLENSKY , A., S CHWARZ , R. & T OMOV , T. (1980) WHO collaborative study on impairments and disabilities associated with schizophrenic disorders. A preliminary communication: objectives and methods. In Epidemiological Research as Basis for the Organization of Extramural Psychiatry (eds E. Strömgren, et al), pp. 152–159. Acta Psychiatrica Scandinavica, 62 (Suppl. 286). JANCA, A., USTÜN, T. B., EARLY, T. S., et al (1993) The ICD–10 symptom checklist – a companion to the ICD–10 classification of mental and behavioural disorders. Social Psychiatry and Psychiatric Epidemiology, 28, 239–242. ——, —— & S ARTORIUS , N. (1994) New versions of World Health Organization instruments for the assessment of mental disorders. Acta Psychiatrica Scandinavica, 90, 73–83. —— & C HANDRASHEKAR , C. R. (1995) Catalogue of WHO Psychiatric Assessment Instruments. Geneva: World Health Organization. —— & H ILLER , W. (1996) ICD–10 checklists – a tool for clinicians’ use of the ICD–10 classification of mental and behavioural disorders. Comprehensive Psychiatry, 37, 180–187. ——, K ASTRUP , M., K ATSCHNIG , H., et al (1996a) The ICD–10 multiaxial system for use in adult psychiatry: structure and applications. Journal of Nervous and Mental Disease, 184, 191–192.

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——, ——, ——, et al (1996b) The World Health Organisation short disability assessment schedule (WHO DAS–S): a tool for the assessment of difficulties in selected areas of functioning of patients with mental disorders. Social Psychiatry and Psychiatric Epidemiology, 31, 349–354. L ORANGER , A., J ANCA , A. & S ARTORIUS , N. (1997) Assessment and Diagnosis of Personality Disorders – the International Personality Disorder Examination (IPDE). Cambridge: Cambridge University Press. MAJ , M., S TARACE , F. & S ARTORIUS , N. (1993) Mental Disorders in HIV-I Infection and AIDS. WHO Expert Series on Biological Psychiatry. Bern: Hogrefe and Huber. ——, J ANSSEN , R., S TARACE , F., et al (1994) WHO neuropsychiatric AIDS study. Archives of General Psychiatry, 5l, 51–61. ROOM , R., J ANCA , A., B ENNETT , L. A., et al (1996) WHO cross-cultural applicability research on diagnosis and assessment of substance use disorders: an overview of methods and selected results. Addiction, 92, 199–220. SARTORIUS , N. & J ANCA , A. (1996) Psychiatric instruments developed by the World Health Organization. Social Psychiatry and Psychiatric Epidemiology, 31, 55–69. SAUNDERS, J. B. & AASLAND, O. G. (1987) WHO Collaborative Project on the Identification and Treatment of Persons with Harmful Alcohol Consumption. Report on Phase I, Development of a Screening Instrument. Geneva: World Health Organization. ——, A ASLAND , O. G., A RUNDSEN , A., et al (1993) Alcohol consumption and related problems among primary health care patients. WHO collaborative project on early detection of persons with harmful alcohol consumption. I. Addiction, 88, 339–352. TSIANTIS, J., CALDWELL, B., DRAGONAS, T., et al (1991) Development of a WHO child care facility schedule (CCFS): a pilot collaborative study. Bulletin of the World Health Organization, 69, 51–57. WHO (1988) WHO Psychiatric Disability Assessment Schedule. Geneva: World Health Organization. —— (1990) WHO Child Care Facility Schedule with User Manual. Geneva: World Health Organization. —— (1992) The ICD–10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization. —— (1993) The Composite International Diagnostic Interview, Core Version 1.1. Washington, DC: American Psychiatric Press. —— (1994) Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Washington, DC: American Psychiatric Association. WING , J. K., C OOPER , J. E. & S ARTORIUS , N. (1974) Measurement and Classification of Psychiatric Symptoms: an Instruction Manual for the PSE and CATEGO Program. Cambridge: Cambridge University Press. ——, B ABOR , T., B RUGHA , T., et al (1990) SCAN: Schedules for clinical assessment in neuropsychiatry. Archives of General Psychiatry, 47, 589–593.


Appendix. WHO designated training and reference centres for SCAN, CIDI and IPDE See also the web sites at Groningen (http://www.psy.med.rug.nl/0018) and Geneva (http://www.who.int/msa/mnh/ems/informat/scan.htm)

Aarhus, Denmark. SCAN Dr Aksel Bertelsen, Dr Ole Mors WHO Collaborating Centre for Research and Training in Mental Health, Aarhus Psychiatric Hospital, DK-8240 Risskov, Denmark Tel: 45 86 17 77 77; Fax: 45 86 17 74 55; Email: [email protected] Language: Danish Status: TRC Ankara, Turkey. SCAN Dr A. Gögüs Department of Psychiatry, Hacettepe University, Ankara, Turkey Tel: 90 4 310 8693; Fax: 90 4 310 1938; Email: [email protected] Language: Turkish Status: TRC Bangalore, India. SCAN, CIDI, IPDE Dr Somnath Chatterji National Institute of Mental Health and Neurosciences, Department of Psychiatry, Post Bag No 2979, Bangalore 560029, India Tel: 91 80 64 21 21 x 221; Tel: 91 80 64 80 73 (home); Fax: 91 80 66 31 830; Email: [email protected] OR [email protected] Language: Hindi/Kannada Status: TRC Beijing, China. SCAN, CIDI Professor Shen Yucun Institute of Mental Health, Beijing Medical College, Beijing 100083, China (People’s Republic of) Tel: 86 1 440 531 (318); Fax: 86 1 202 7314; Email: [email protected] Language: Chinese Status: TRC

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Groningen, The Netherlands. SCAN Dr Fokko Nienhuis, Professor Robert Giel Department of Social Psychiatry, Postbus 30.001, 9700 RB Groningen, The Netherlands Tel: 31 50 361 2077; Fax: 31 50 361 9722; Email: [email protected] Language: Dutch Status: TRC Amsterdam, The Netherlands. CIDI Dr R. Smeets Psychiatric Clinic, Academisch Ziekenhuis, Universitiet van Amsterdam, Tafelbergweg 25, 1105 BC Amsterdam Zuidoost, The Netherlands Lübeck, Germany. SCAN Professor H. Dilling Klinik für Psychiatrie der Medizinischen Hochschule, Ratzeburger Allee 160, 2400 Lübeck 1, Germany Tel: 49 451 500 2440; Fax: 49 451 500 2603; Email: [email protected] Language: German Status: GER–TRC Mannheim, Germany. SCAN Professor H. Häfner, Dr K. Maurer Zentralinstitut für Seelische Gesundheit, Quadrat J.5, Postfach 12 21 20, 68072 Mannheim, Germany Tel: 49 621 1703 726/+49 621 1703 744; Fax: 49 621 234 29/ 49 621 1703 266; Email: [email protected] or [email protected] Language: German Status: GER–TRC Munich, Germany. CIDI Dr H.-U. Wittchen Max-Plank Institute fur Psychiatrie, Kraepelinstrasse 10, 8000 Munich 40, Germany Athens, Greece. SCAN Dr V. G. Mavreas University Research Institute of Mental Health, Eginition Hospital, 74, Vas. Sophias Avenue, 11528 Athens, Greece Tel: 30 1 724 7618; Fax: 30 1 729 3244; Email: [email protected] Language: Greek Status: TRC

Assessment instruments 81 Luxembourg, Luxembourg. SCAN, CIDI, IPDE Professor Charles Pull Centre Hospitalier de Luxembourg, Service de Neuropsychiatrie, 4, rue Barblé, Luxembourg Tel: 352 4411-2706; Fax: 352 441 247; Email: [email protected] Language: French Status: TRC Nagasaki, Japan. SCAN Professor Y. Nakane Department of Neuropsychiatry , University of Nagasaki, 7-1, Sakomoto-Machi, Nagasaki 852, Japan Tel: 81 958 47 21 11 x 2860; Fax: 81 958 49 72 96; Email: [email protected] Language: Japanese Status: TRC Perth, Australia. SCAN Professor A. Jablensky University Department of Psychiatry, Medical Research Foundation Building, 50 Murray Street, Perth WA 6000, Australia Tel: +61 8 9224 0290; Fax: +61 8 9224 0285; Email: [email protected] Language: English Status: TRC Puerto Rico, USA (Spanish). CIDI Dr M. Rubio-Stipec Department of Academic Affairs, Office of the Dean University of Puerto Rico, Medical Sciences Campus, GPO Box 5067, San Juan, PR 00936, USA Sydney, Australia. CIDI Dr Gavin Andrews Clinical Research Unit for Anxiety Disorders, St Vincent’s Hospital, 299 Forbes Street, Darlinghurst, NSW 2010, Australia Tel: 61 2 332 1188; 4312; Fax: 61 2 332 4316; Email: [email protected] Santander, Spain. SCAN Professor J. L. Vázquez-Barquero Clinical and Social Psychiatric Research Unit, University Hospital ‘Marqués de Valdecilla’, Avda. Valdecilla s/ n. 39008 Santander, Spain Tel: +34-(9)42-202545 / 203446; Fax: +34-(9)42-203447 / 202655 Email: [email protected] OR [email protected] Language: Spanish Status: TRC

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São Paulo, Brazil. SCAN Dr F. Lotufo Neto, Dr L. Andrade Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, CEP: 01251-110, Sao Paulo SP, Brazil Tel: 55 11 210 4311; Fax: 55 11 659 062; Email: [email protected] Language: Portuguese Status: TRC São Paulo, Brazil. CIDI Dr C. Torres de Miranda Departemendo de Psiquiatria, Escola Paulista de Medicina, Rua Botucatu 740, Sao Paulo SP, CEP: 04023, Brazil London, UK. SCAN Professor Paul Bebbington Department of Psychiatry and Behavioural Sciences, Archway Wing, Whittington Hospital, Highgate Hill, London N19 5NF Tel: 44 171 288 3558 (secretary); Tel: 44 171 288 3551 (direct); Fax: 44 171 288 3411; Email: [email protected] Language: English Status: UK–TRC Secretary Leicester, UK. SCAN Dr Terry Brugha Department of Psychiatry, Section of Social Psychiatry, Brandon Mental Health Unit, Leicester General Hospital, Gwendolan Road, Leicester LE5 4PW Tel: 44 116 225 6295; Fax: 44 116 225 6312; Email: [email protected] Language: English Status: UK–TRC Manchester UK. SCAN Dr Paul Strickland Neurosciences and Psychiatry Unit, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT Tel: 44 161 275 7427; Fax: 44 161 275 7429; Email: [email protected] Language: English Status: UK–TRC

Assessment instruments 83 Nottingham, UK. SCAN Professor Peter Jones Professorial Unit, Mapperley Hospital, Porchester Road, Nottingham NG3 6AA Tel: 44 115 952 9485; Fax: 44 115 955 5352; Email: [email protected] Language: English Status: UK–TRC Baltimore, USA. SCAN Dr A. Romanoski Johns Hopkins Hospital, Meyer Building Room 4181, 600 N Wolfe Street, Baltimore, MD 21287-7481, USA Tel: 1 410 955 7011; Fax: 1 410 614 8761; Email: [email protected] Language: English Status: US–TRC Farmington, USA. SCAN Dr T. Babor School of Medicine, Department of Psychiatry, University of Connecticut Health Centre, Farmington, CT 06032, USA Tel: 1 203 679 3423; Fax: 1 203 679 1296; Email: [email protected] Language: English Status: US–TRC St. Louis, USA. SCAN Dr Wilson M. Compton III Department of Psychiatry, Washington University, School of Medicine, 4940 Children’s Place, St Louis, MO 63110, USA Tel: 1 314 286 2261; Fax: 1 314 286 2265; Email: [email protected] Language: English Status: US–TRC St. Louis, USA. CIDI Dr Lee Robins Department of Psychiatry, Washington University School of Medicine, 4940 Childrens Place, St Louis, MO 63110, USA New York, USA. IPDE Dr A. Loranger The New York Hospital, Cornell Medical Center, 21 Bloomingdale Road, White Plains, NY 10605, USA

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Verona, Italy. SCAN Dr M. Tansella, Dr Nicolaou Stylianos Institute of Psychiatry, University of Verona, 37134 Verona, Italy Tel: 04 58 07 49 52; Fax: 39 45 58 58 71; Email: [email protected] Language: Italian Status: FTC

Epidemiology of schizophrenia

Part II. Contributions to knowledge

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WHO’s contribution to the epidemiology of schizophrenia HEINZ HÄFNER

Introduction The attempt to analyse what 25 years of epidemiological research by WHO’s Mental Health Division under Norman Sartorius have contributed to our knowledge of schizophrenia has turned out to be a fascinating exercise. How was it possible, with only a handful of scientists, to conduct an epidemiological research programme that was the most comprehensive ever planned in terms of the questions addressed and the space and time covered? The WHO programme on psychiatric epidemiology dates back to 1959, when the first tentative principles and objectives for WHO’s mental health programme were formulated. In 1964 a group of leading scientists – including Leon Eisenberg and Carlos Leon – recommended that epidemiology be given high priority in WHO’s mental health research. John M. Last’s (1983) definition of epidemiology, “the study of the distribution and determinants of healthrelated states and events in populations and the application of this study to control health problems” (p. 32f), reads like the core of WHO’s research programme. Indeed, epidemiology is the basic science underlying all public health activities – from the assessment of the ecological, biological and psychosocial determinants of health and illness in populations to the evaluation of preventive interventions and health services. Epidemiology also has instrumental aspects. One of these is the methodological arsenal, whose aim is to ensure the external validity or applicability of health-related research results achieved on samples of individuals in specific populations (such as findings on needs for care at the level of a community or on disease costs at a national level). 87

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The final stage of generalisation is the transnational, or global, level: the world population. The role of these levels in mental health problems pertains not only to the questionable assumption of human beings’ common disposition to respond to different agents or stressors, but also to the internationalisation of medical knowledge, pharmaceutical markets, and substance misuse, to the worldwide expansion of tourism and the media, and to rapid changes in traditional lifestyles and cultures. The aim of this chapter is to provide an overview of WHOcoordinated work on the epidemiology of schizophrenia; I believe that the unique features of this work (its cross-cultural structure, the high degree of methodological sophistication reached and the large number of clinicians and researchers involved) represent one of the most important achievements of this century in the overall field of psychiatry.

Prerequisites for worldwide comparative epidemiological studies Common definitions and common diagnostic criteria are essential prerequisites for transnational comparisons or a global applicability of results, together with standardised instruments and procedures for collecting reliable data on health-related events across political, linguistic and cultural units. Variation occurs not only in the physicochemical, socio-economic and cultural conditions and in the environmental risk factors to which people are exposed, but also in the genetic and psychosocially determined susceptibility of individuals or populations. Alcohol misuse and related disorders are a classic example of a health problem determined by factors located at various levels, and to some extent unevenly distributed across cultures and nations. A series of transnational studies coordinated by the WHO Mental Health Division have revealed the influence that historical and cultural conditions, micro-social and familial factors, age, gender and socio-economic circumstances, as well as the availability of alcoholic beverages, have on the drinking habits and alcohol consumption of populations. The risk is also strongly dependent on biological susceptibility, determined by an inherited deficiency of ALDH-1 (aldehyde dehydrogenase activity), which is primarily encountered in Asian populations (Rootman & Moser, 1985; Walsh & Grant, 1985; Fillmore et al, 1988; Yamashita et al, 1990). Epidemiological knowledge of the way individual susceptibility, risk and protective factors interact and vary among populations contributes to the understanding of the differences in the distribution of alcohol dependence


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and its complex aetiology. It also provides a valuable basis for population-specific preventive programmes. This example illustrates the value of multilevel approaches and comparative epidemiological studies across populations in achieving a better understanding and a more effective prevention of complex substance-related and behavioural disorders.

Some historical notes on psychiatric epidemiology The planning phase of the WHO transnational mental health research programme took place during a controversial moment in the history of psychiatric epidemiology. In Europe, population studies traditionally used categorical case definitions based on the Kraepelinian classification system. Examples are the surveys of total populations conducted by Brugger (1933) in Thuringia and Bavaria, by Strömgren (1938) on the island of Bornholm, and by Essen-Müller (1956) in the Swedish community of Lundby, near Lund. Their aim was to collect data not only on restrictively defined morbidities, mostly psychoses, but also on their genetic inheritance and mode of transmission. In the USA, psychiatric epidemiology adhered primarily to a unidimensional concept of socially determined mental dysfunctioning. In 1955, for example, the National Advisory Mental Health Council stated that “the concept of etiology as embraced by modern psychiatry differs from the simple cause and effect system of traditional medicine. It subscribes to a ‘field theory’ hypothesis in which the interactions and transactions of multiple factors eventuate in degrees of health and sickness” (cited in Klerman, 1990, p. 29). In contrast, genetic and biological factors were neglected (Klerman, 1990). But the large population studies based on the social field theory of a purely social causation of mental dysfunction did not produce many decidedly new findings, as stressed by Mishler & Scotch (1963) in their review of epidemiological research on schizophrenia: “Writing ... a review of studies of the social aetiology of schizophrenia is like talking with the relatives of the deceased after returning from a funeral. Other than some platitudes, there is little that can be suggested that would remedy, alleviate or eliminate the trouble ... few studies are available, concepts and methods are unclear and unstandardized, findings are inconsistent and speculation abounds in the absence of reliable empirical knowledge” (p. 340). In practice, both the social reform programmes and the universal therapy approaches, such as psychoanalysis in the prevention of severe mental disorders, failed completely.

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In contrast, the new modes of therapy developed in the meantime, like psychotropic drugs and cognitive–behavioural therapy, showed some diagnostic and clear syndrome specificity, thus rendering global measures of mental dysfunction worthless even for the purpose of planning services. What was needed were diagnosis- and symptomspecific data. It was Robins & Guze’s call for precise diagnostic definitions and their empirical validation, published in 1970, that brought about the neo-Kraepelinian turn in the USA, which led to the construction of the DSM–III and a process that gradually closed the gap with the European tradition and the conceptual basis of the ICD. Thus, according to Bruce Dohrenwend (1989), psychiatric epidemiology in the USA entered its third period after a phase of studies conducted with categorical case definitions, but still flawed by methodological shortcomings. In this period, which featured the Epidemiologic Catchment Area (ECA) project (Regier et al, 1984) carried out in five different communities, the conceptual and instrumental requirements for obtaining valid and internationally comparable results from population studies were fulfilled.

The WHO programme on psychiatric epidemiology As early as its planning phase in the 1960s the WHO programme on psychiatric epidemiology applied a categorical approach to the Kraepelinian tradition, which was also followed by a great number of non-European countries such as the British Commonwealth countries and Japan. Thanks to its strictly empirical orientation and its innovative research strategy the programme soon acquired the role of an international pace setter, anticipating Robins & Guze’s neo-Kraepelinian principles. The programme fulfilled all the main requirements for transnational comparative epidemiology, namely: (1) the standardisation of diagnosis, classification and statistical reporting; (2) the development of standardised, internationally applicable instruments for a reliable assessment of mental patients and variables; (3) the performance of studies on the incidence and prevalence of mental disorders; and (4) the training of mental health workers in epidemiological and social aspects of psychiatry (Sartorius, 1976, 1993). During the first phase the researchers developed instruments for a standardised assessment of symptoms, syndromes, diagnoses, and case histories, and later also of long-term course, functional impairment (Psychiatric Impairment Rating Schedule, or PIRS), and disability (Disability Assessment Schedule, or DAS), as well as an internationally


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accepted classification (ICD–8) based on the Kraepelinian system. With the help of a small team of excellent and extremely hardworking scientists, Sartorius managed to create a worldwide network of investigators. The planning and execution of the trans-national epidemiological multicentre projects has helped to spread the classification criteria, research methods, practice and knowledge across countries and continents, thus contributing to the advances in the mental health discipline worldwide.

WHO studies on schizophrenia The focus of this chapter is on WHO-coordinated schizophrenia studies which, for good reason, formed the core of the programme. The International Pilot Study of Schizophrenia (IPSS) (WHO, 1973, 1979), launched in 1968, was the first large-scale transnational multicentre study undertaken by WHO, and was thus a venture into a new domain. A total of 1202 people aged 15 to 44 were selected through TABLE 6.1 Main features of the IPSS and the DOSMED studies on schizophrenia IPSS

DOSMED

Field centres

Aarhus (DK), Agra (India), Cali (Colombia), Ibadan (Nigeria), London (UK), Moscow (USSR), Prague (Czechoslovakia), Taipei (Taiwan), Washington (USA)

Patients

1202 aged 15–44 years

Aarhus (DK), Agra (India), Chandigarh (India), Cali (Colombia), Dublin (Ireland), Ibadan (Nigeria), Moscow (USSR), Nagasaki (Japan), Nottingham (UK), Prague (Czechoslovakia), Honolulu (USA), Rochester (USA) Initially screened: 1538 Cases included in study population: 1379 Cases with a diagnosis of schizophrenia ICD–9 295: 1151

Inclusion criteria

Presence of psychotic symptoms

Exclusion criteria

Gross organic brain pathology, chronicity, alcohol- or drug dependence, sensory defects, mental retardation

Data from WHO (1973) and Jablensky et al (1992)

(i) age 15–54 years (ii) presence, in the preceding 12 months, of psychotic symptoms or of abnormalities suggestive of psychotic disorder (iii) first-in-lifetime contact with any helping agency within the last 3 months due to (ii) Evidence of gross brain pathology, including CNS damage due to alcohol or drug abuse

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F IG . 6.1 Study population of the ‘Determinants of Outcome’ study by diagnostic categories (total screening population: 1538). Source: Jablensky et al, 1992 (modified).

subsequent hospital admissions using the inclusion and exclusion criteria stated in Table 6.1. The patients were examined with regard to their case histories, social aspects, symptomatology and diagnostic scores and classes. The very first finding was not unexpected. In all the populations and cultures, study patients with a clinical diagnosis of schizophrenia showed high PSE scores for the characteristic symptoms: lack of insight, suspiciousness, delusional mood, delusions or ideas of reference and persecution, flatness of affect, auditory hallucinations and delusions of being controlled by an external agent. The finding thus confirmed Kraepelin’s categorical position. Despite the variability of individual symptoms, the core of the disorder was clearly the same in all the populations and cultures investigated. It seems to be accounted for by factors that all people with schizophrenia in any country or culture have in common. For this reason, biological explanations of its aetiology appear more plausible than environmental ones. There are, however, still many important questions left in schizophrenia research that require a trans-cultural approach. The IPSS could not explain the considerable transnational variation in the incidence rates of schizophrenia, and this issue was addressed in the WHO study called Determinants of Outcome of Severe Mental Disorders (Jablensky et al, 1992). The inclusion criteria were expanded to encompass negative symptoms and severe behavioural disorders and an age range of 15 to 54 years, in order to ensure a better coverage of the risk period (Table 6.1). By applying a search strategy for first-onset

Epidemiology of schizophrenia 93

F IG . 6.2 Profiles on 44 selected PSE items of 586 people in developing countries and 783 people in developed countries, all meeting ‘broad’ diagnostic criteria for schizophrenia and related disorders. Source: Sartorius et al (1986).

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cases, an attempt was made to identify in the catchment populations all first-in-lifetime contacts with any helping agency (ranging from other medical to non-medical agencies like police and native healers) by persons fulfilling the inclusion criteria. The study was begun in late 1978; 1538 cases were selected at the initial screening, 1379 were included in the study population and 1151 patients received a restrictive clinical diagnosis of schizophrenia (ICD–9, 295) (Fig. 6.1). The outcome of the study confirmed the trans-cultural similarity of the schizophrenic syndrome. Figure 6.2 shows the PSE-item or symptom profiles of patients from developed and developing countries. The excellent design of the study enabled the testing of several interrelated hypotheses (Fig. 6.3). Additional instruments were developed (Psychiatric and Personal History Schedule or PPHS; Follow-up Psychiatric and Personal History Schedule or FU–PPHS; Diagnostic and Prognostic Schedule or DPS) in an attempt to operationalise the variables studied, especially functional impairment (PIRS) and social disability (DAS), and to obtain information on symptom-related and social course. Some of the centres included studies of life events, family atmosphere according to the expressed emotion paradigm, impairment, disability, and illness perception, using two sub-cohorts. An almost revolutionary finding was very similar annual incidence rates for a precise, restrictively defined diagnosis, CATEGO S+ (nuclear schizophrenia), the mean rate being 10/100 000 (Fig. 6.4). That result has been replicated in several later studies using comparable methodologies: for example, in our ABC Schizophrenia Study conducted on a population of 1.5 million in Germany we came up with similar incidence rates (Hambrecht et al, 1994). It has also been confirmed by a validation study of all first admissions in 1976 for a diagnosis of schizophrenia (ICD 295) from the Danish case register (Löffler et al, 1994). Together with our Danish colleagues, we examined the original case-notes of a random sample of these first admissions to mental hospitals and units in Denmark, and found substantially higher proportions of the operational diagnosis of CATEGO ICD 295 as compared with the corresponding clinical diagnosis (Table 6.3). If allowance is made for the fact that Danish psychiatrists tend to underdiagnose ICD–9 295 schizophrenia considerably and in females still more so than in males, the true rates for the Aarhus Determinants of Outcome study sample (5/100 000 for females and 9/100 000 for males) are fairly close to the 10/100 000 mean rate of the other centres (Löffler et al, 1994). Figure 6.4 presents three groups of annual incidence rates: (1) from eight selected national incidence studies (Häfner, 1992) differing in the diagnostic procedures used; (2) from the outcome study as based on a broad diagnosis of ICD 295-CATEGO S, P and O;


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F IG . 6.3 Schematic representation of the design of the WHO Collaborative Study on Determinants of Outcome of Severe Mental Disorders (Jablensky et al, 1992).

and (3) a precise diagnosis of S+. A comparison of the three groups demonstrates that the differences disappear when precise diagnoses are used. The differences observed, then, were obviously accounted for by diagnostic artefacts.

96 Häfner

WHO Determinants of Outcome Study

F IG . 6.4 Incidence rates from selected national studies and the WHO Determinants of Outcome Study per 100 000 population, aged 15–54 (male and female), and for a ‘broad’ and ‘restrictive’ definition of schizophrenia. Source: Sartorius et al (1986), supplemented by Mannheim data (Hambrecht et al, 1994).


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TABLE 6.2 Distribution of clinical ICD–8 diagnoses and CATEGO–ICD– diagnoses at index admission (Danish case notes sample) 1 Clinical ICD–8 diagnoses 295 Men N 27 % 49.1 Women N 17 % 27.9 Total N 44 % 37.9

CATEGO ICD–8 diagnoses

2 9 7 298.3 301.83 Total

295

297

2 9 6 300.0/4

Total

8 14.6

15 27.3

5 55 9.1 100.0

31 63.3

10 20.4

6 12.2

2 4.1

49 100.0

21 34.4

19 31.2

4 61 6.6 100.0

36 62.1

13 22.4

8 13.8

1 1.7

58 100.0

29 25.0

34 29.3

9 116 7.8 100.0 P < 0.05

67 62.6

23 21.5

14 13.1

3 107 2.8 100.0 Not significant

1. Fisher’s exact test. Source: Löffler et al (1994).

Besides the transnational similarity of the syndrome and the morbidity risk, consistent patterns of age distribution at onset and gender differences in age of onset were also found (Fig. 6.5). The value of these results is reflected in research projects and perspectives that have emerged in their wake. One example is our ABC schizophrenia study. In that study, on the basis of the distribution patterns across the male and female life cycles, we hypothesised that oestrogen might raise the vulnerability threshold for schizophrenia and in this way delay its outbreak in females. In animal experiments we showed that a chronic administration of oestrogen is capable of reducing D2 receptor sensitivity and, consequently, dopamine-induced behaviour (Häfner et al, 1991). In clinical tests we demonstrated that in females with acute schizophrenic symptoms and normal menstrual cycles schizophrenic symptoms were indeed negatively correlated with oestrogen levels, and thus proved the applicability of the neuro-hormonal model of explanation to human schizophrenia. In contrast, depressive symptoms were not influenced by oestrogen levels (Häfner et al, 1993). The findings of identical symptoms, an identical morbidity risk and similar patterns of distribution over age and sex – which might be called an epidemiological anomaly – only apply to the phenotype, as stressed by Assen Jablensky (1986). They cannot be interpreted as suggesting a uniform aetiology. An obvious conclusion is that the schizophrenic syndrome might be one of the human brain’s few preformed patterns of response to various noxious agents and, therefore, as Jablensky (1988) has called it, a final common pathway. It might be explained by a common patho-physiological mechanism located at a relatively non-specific level of functioning involving dopaminergic neurotransmission (Häfner, 1992).

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TABLE 6.3 Pattern of course (two-year follow-up) by type of onset and setting (percentages) in the DOSMED study Pattern of course Setting Developed countries c 2 = 40.3 P < 0.001

Type of onset Acute Subacute Gradual All types Developing countries Acute c 2 =26.4 Subacute P < 0.001 Gradual All types

Mild 51.1 41.3 29.8 38.9 62.0 58.7 40.2 55.7

Intermediate 25.1 23.9 17.5 21.1 21.0 23.8 16.3 20.2

Severe 22.6 34.7 52.6 39.8 16.9 17.4 43.4 24.0

Source: Jablensky et al (1992).

Course and outcome of schizophrenia as shown by WHO studies The IPSS, too, had been designed as a follow-up study. Of the 1202 cases, 77% were examined with PSE interviews two years after the initial examination and 74% at five years. The results confirmed a number of findings from other long-term follow-up studies, for instance a relatively high stability of the diagnosis and a clearly less favourable outcome compared with affective psychosis. The most surprising finding was a less favourable course and outcome in the developed than in the developing countries, regardless of whether total time spent with psychotic symptoms, patterns of course (as defined by relapses and residual states), or social impairment was used as the criterion. Two-year data analysed thus far from the outcome study have confirmed the finding for all subtypes of the disorder and all forms of onset. The hypotheses tested in the outcome study, such as differences in family atmosphere (Wig et al, 1987a,b), type and frequency of life events (Day et al, 1987) and illness perception (Katz et al, 1988), have all failed to provide a conclusive explanation for the difference. Diagnostic artefacts and a higher proportion of acute transient psychoses with a schizophrenic phenotype in developing countries were also excluded, as shown in Table 6.3. Outcome was better in the developing countries irrespective of whether onset was acute, sub-acute or gradual (Jablensky et al, 1992). In view of these findings, differences in socio-cultural, geographical or climatic conditions do not appear to have any essential influence on the symptomatology, morbidity risk and demographic distribution pattern of the schizophrenic syndrome. The pronounced differences


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F IG . 6.5 WHO Study – mean age at first admission. Source: Hambrecht et al (1992).

in course and outcome are attributed to unknown factors that the environment or people in developed and developing countries – two very global categories – seem to share respectively. Psychosocial variables, currently the focus of interest, do not seem to provide a plausible explanation either, considering the results of the outcome study. Norman Sartorius has left his successor a clearly defined task for the next phase of work. In the meantime, the WHO Coordinated Study on the Long-term Course and Outcome of Schizophrenia has begun (Sartorius et al, 1996). Its aim is to collect information on course and outcome on the cohort of the WHO Collaborative Study on Psychiatric Disability approximately 15 years after first admission, and on the IPSS cohort some 25 years after first admission, using the same instruments as before. Consequently, reliable new findings on the long-term course and outcome of symptoms, functional impairment, social disability and social status are bound to emerge in the future. In the Mannheim cohort of the WHO Disability Study, followed up by seven cross-sectional assessments over five years (Fig. 6.6), the three main measures – positive and negative symptom score (PSE) and disability score (DAS) – showed a surprising degree of stability after the first episode, though individual variation occurred. Preliminary results from a 14-year follow-up of this cohort show that the mean values and profiles of social disability (DAS) and

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symptomatology (CATEGO syndromes) were more or less unchanged 1.5 and 14 years after first admission (Fig. 6.6). These results have important theoretical and practical implications. They suggest that, rather than a lifelong deteriorating illness like dementing brain disease, schizophrenia seems to be a self-limiting process that starts early and, after an initial phase of marked accumulation of symptoms and impairments, comes to a standstill at a reduced level of social and cognitive functioning, with the labile balance occasionally shaken by outbursts of acute psychotic symptoms or episodes.

Concluding remarks This chapter was not intended to address the contributions that the other WHO large-scale transnational multi-centre studies (such as the Study on Depressive Disorders in Different Cultures), along with numerous minor investigations, have made to our knowledge of mental disorders. The focus of the epidemiological research conducted by the Mental Health Division over the past 25 years has been the accumulation of knowledge about frequently occurring disorders involving severe health and social consequences and having a considerable impact on public health. It is in this field that its work has been most successful, although one key issue – the aetiology of

F IG . 6.6 WHO Disability Study: Mannheim cohort. Comparison of mean scores over time. Source: Biehl et al (1988).


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schizophrenia – still remains unsolved, and the question of explaining the differences in course and outcome between developing and developed countries has resurfaced. Nevertheless, the advances in knowledge are of considerable theoretical importance for generating new hypotheses about the aetiology and primary prevention of the disorder. They are of considerable practical value for a world-wide standardisation of services, preventive treatment and rehabilitation strategies. The instruments, methods and experience gained through 25 years of WHO’s work on the epidemiology of mental disorders have led to important new findings, but they have also paved the way for future studies of a standard not comparable with that in the 1960s. The programme has also produced a world-wide network of excellent scientists and centres ‘willing and able to work together’, as Norman Sartorius (1993) recently stated with justified pride. It is likely that all of this will help further what has been, so far, a most successful period of psychiatric epidemiological research – even though the captain of the small but excellent crew, who has steered his vessel with a steady hand over the stormy oceans of the world, has left the helm.

References B IEHL , H., M AURER , K. & S CHUBERT , C. (1988) Dimensionen der Psycholopathologie und sozialen Anpassung im natürlichen Verlauf schizophrener (Erst-) Erkrankungen. In: Prospektive Verlaufsforschung in der Psychiatrie (ed. R. K. Olbrich). Heidelberg: Springer-Verlag. B RUGGER , C. (1933) Psychiatrische Ergebnisse einer medizinischen, anthropologischen und soziologischen Bevölkerungsuntersuchung. Zeitschrift für Neurologie und Psychiatrie, 146, 489–524. DAY , R., N IELSEN , J. A., K ORTEN , A., et al (1987) Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization. Culture, Medicine, and Psychiatry, 11, 123–205. D OHRENWEND , B. P. (1989) The problem of validity in field studies of psychological disorders revisited. In The Validity of Psychiatric Diagnosis (eds L. N. Robins & J. E. Barrett), pp. 35–55. New York: Raven Press. ESSEN -M ÜLLER , E. (1956) Individual traits and morbidity in a Swedish rural population. Acta Psychiatrica et Neurologica, (Suppl. 100). FILLMORE , K. M., G RANT , M., H ARTKA , E., et al (1988) Collaborative longitudinal research on alcohol problems. British Journal of Psychiatry, 83, 441–444. HÄFNER, H. (1992) The epidemiology of schizophrenia. Triangle, 31, 133–154. ——, B EHRENS , S., D EV RY , J., et al (1991) An animal model for the effects of estradiol on dopamine-mediated behavior: Implications for sex differences in schizophrenia. Psychiatry Research, 38, 125–134. ——, R IECHER -R ÖSSLER , A., VAN DER H EIDEN , W., et al (1993) Generating and testing a causal explanation of the gender difference in age at first onset of schizophrenia. Psychological Medicine, 23, 925–940. HAMBRECHT , M., M AURER , K., S ARTORIUS , N., et al (1992) Transnational stability of gender differences in schizophrenia. European Archives of Psychiatry and Clinical Neurosciences, 242, 6–12.

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——, R IECHER -R ÖSSLER , A., F ATKENHEUER , B., et al (1994) Higher morbidity risk for schizophrenia in males: fact or fiction? Comprehensive Psychiatry, 35, 39–49. JABLENSKY , A. (1986) Epidemiology of schizophrenia: A European perspective. Schizophrenia Bulletin, 12, 52–73. —— (1988) Epidemiology of schizophrenia. In The Major Issues (eds P. Bebbington & P. McGuffin), pp. 19–35. Oxford: Heineman Professional Publishing. ——, S ARTORIUS , N., E RNBERG , G., et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine Monograph (Suppl. 20). KATZ, M. M., MARSELLA, A. & DUBE, K. C., et al (1988) On the expression of psychosis in different cultures: schizophrenia in India and in a Nigerian community: a report from the World Health Organization project on determinants of outcome of severe mental disorders. Culture, Medicine, and Psychiatry, 12, 331–355. KLERMAN, G. (1990) Paradigm shifts in USA psychiatric epidemiology since World War II. Social Psychiatry and Psychiatric Epidemiology, 25, 27–32. LAST, J. M. (1983) A Dictionary of Epidemiology. Oxford: Oxford University Press. LÖFFLER , W., H ÄFNER , H., F ÄTKENHEUER , B., et al (1994) Validation of Danish case register diagnosis for schizophrenia. Acta Psychiatrica Scandinavica, 90, 196–203. M ISHLER , E. G. & S COTCH , N. A. (1963) Sociocultural factors in the epidemiology of schizophrenia. A review. Psychiatry, 26, 315–351. REGIER , D. A., M YERS , J. K., K RAMER , M., et al (1984) The NIMH epidemiologic catchment area (ECA) program: historical context, major objectives and study population characteristics. Archives of General Psychiatry, 41, 934–941. Robins, E. & Guze, S. B. (1970) Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. American Journal of Psychiatry, 126, 983–987. ROOTMAN , I. & M OSER , J. (1985) Community Response to Alcohol-related Problems. A World Health Organization Project Monograph. National Institute on Alcohol Abuse and Alcoholism. DHHS Publication No. (ADM) 85-1371. Washington: National Institute of Public Health. S ARTORIUS , N. (1976) Classification: an international perspective. Psychiatric Annals, 6, 22–35. ——, J ABLENSKY , A., K ORTEN , A., et al (1986) Early manifestations and first-contact incidence of schizophrenia in different cultures. Psychological Medicine, 16, 909–928. —— (1993) WHO’s work on the epidemiology of mental disorders. Social Psychiatry and Psychiatric Epidemiology, 28, 147–155. ——, G ULBINAT , W., H ARRISON , G., et al (on behalf of the collaborating investigators) (1996) Long-term follow-up of schizophrenia in 16 countries: A description of the International Study of Schizophrenia conducted by the World Health Organization. Social Psychiatry and Psychiatric Epidemiology, 31, 249–258. STRÖMGREN, E. (1938) Beiträge zur psychiatrischen Erblehre, auf Grund von Untersuchungen an einer Inselbevölkerung. Acta Psychiatrica et Neurologica (Suppl. 19). WALSH , B. & G RANT , M. (1985) Public Health Implications of Alcohol Production and Trade. WHO Offset Publication No. 88. Geneva: WHO. WHO (1973) Report of the International Pilot Study of Schizophrenia, Volume 1. Geneva: WHO. —— (1979) Schizophrenia: an International Follow-up Study. Chichester: John Wiley & Sons. WIG , N. N., M ENON , D. K., B EDI , H., et al (1987a) Expressed emotion and schizophrenia in North India: cross-cultural transfer of ratings of relatives’ expressed emotion. British Journal of Psychiatry, 151, 156–160. ——, M ENON , D. K., B EDI , H., et al (1987b) Expressed emotion and schizophrenia in North India: II. Distribution of expressed emotion components among relatives of schizophrenic patients in Aarhus and Chandigarh. British Journal of Psychiatry, 151, 160–165. YAMASHITA , I., O HMORI , T., K OYAMA , T., et al (1990) Biological study of alcohol dependence syndrome with reference to ethnic difference: report of a WHO collaborative study. Japanese Journal of Psychiatry and Neurology, 44, 70–84.

Biological research in psychiatry

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Biological research in psychiatry within the WHO programme on mental health JULIEN MENDLEWICZ

Introduction The World Health Organization (WHO) recognised the importance of biological research in mental health almost from the start of the Mental Health Division’s activities. As early as 1964, the DirectorGeneral convened the first Scientific Group on Mental Health Research, during which experts drew attention to the lack of firm knowledge in the aetiology and pathogenesis of mental disorders. They emphasised the need for improved education and training of psychiatrists in research methodology, including biological research in psychiatry and allied disciplines. Subsequently, the Division of Mental Health has carried out a large number of collaborative studies in the field of biological psychiatry and psychopharmacology. Generally speaking, the activities in this area can be divided into three main groups:

organisation of research projects, including multi-centre collaborative trials organisation of training for specialists in developing countries exchange of scientific information.

More than 23 centres from 19 countries all over the world have been involved in these activities over the years. For instance, within approximately the last two decades, WHO has completed 14 collaborative studies, whose results have either been published or submitted for publication (Morozov, 1981, 1984, 1985a,b, 1986a). 103

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WHO-coordinated biological research on affective disorders A large part of WHO-coordinated biological research in psychiatry has explored the characteristics of depressive disorders and their pharmacological treatment. Genetic linkage of bipolar manic-depressive illness and red/green colour blindness was examined on sixteen pedigrees identified and analysed in a collaborative study involving four centres – Basel, Bethesda, Brussels and Copenhagen: Fig. 1 illustrates one such pedigree (Gershon et al, 1980). This study led to the conclusion that bipolar illnesses are heterogeneous. It also illustrated one of the advantages of collaborative studies, namely the faster accumulation of data on rare cases, such as those in which bipolar illness and colour blindness coincide. A study of the effectiveness of antidepressant medication was conducted by a network of centres in Basel, Bethesda, Copenhagen, Epsom, Gröningen, Moscow and Munich (Coppen et al, 1987). In this study, plasma levels of amitriptyline were measured and correlated with clinical responses assessed with standardised instruments. No significant correlation, however, was established. One specific area of investigation was the effectiveness of antidepressant drugs studied in Basel, Bombay, Cali, Lucknow, Nagasaki, Nashville and Sapporo (Morozov, 1986b). Three striking findings emerged: firstly, that antidepressant treatment is effective in a vast majority of cases; secondly, that there are few, if any, differences in treatment effects between low and high doses of antidepressant drugs;

F IG . 1 Pedigree indicative of X-linkage of manic–depressive illness.


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and thirdly, that most of the differences in dosage across countries can be explained by the diagnostic and therapeutic habits of psychiatrists. Several studies on the biological markers of depressive disorders have also been completed (Mendlewicz, 1984). In one study, centres in Athens, Brussels, Mexico, Munich, Naples, Sapporo, Tokyo and Zagreb examined sleep-EEG abnormalities in major depression (Mendlewicz & Kerkhofs, 1991). Compared with control subjects, depressed patients showed greater sleep-continuity disturbances (such as an increase in sleep-onset latency), and lower total sleep time and sleep efficiency. Stages 2 and 3 were reduced in depressed patients, while REM latency was shortened and REM density increased. Figure 2 illustrates some sleep EEG findings in depression. These findings confirmed the presence of specific sleep-EEG disturbances in major depression and the influence of the severity of illness on sleep continuity and REM sleep. In another study, centres in Athens, Basel, Brussels, Copenhagen, Irvine, Milan/Naples, Moscow, Munich, and Tokyo examined a total of 154 depressed patients and 130 healthy controls to assess whether the number of imipramine platelet binding sites can be used as a biological marker of endogenous depression (Mellerup et al, 1984; Bech et al, 1986a,b, 1988). This could not be proven, but the researchers did not dismiss the possibility that differences in the number of binding sites may exist among subgroups of depressed patients. The usefulness of the dexamethasone suppression test in depression has also been investigated (Gastpar et al, 1992), and comparisons have been made between the effectiveness of oral and intravenous routes for the administration of medication (Gastpar et al, 1986). (a)

(b)

F IG . 2 Distribution of REM latency in (a) control and (b) depressed subjects (3rd night).

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A multi-centre study on depression and cognitive impairment in the elderly has been conducted jointly by two Swiss university departments and the World Health Organization, with two main goals: (1) to develop assessment methods which could then be used in the Swiss centres in a standardised fashion; and (2) to produce new knowledge about the distinction between depression and cognitive impairment and between dementia and pseudodementia. This study has shown that a variety of instruments can be used for the reliable assessment of depression or cognitive impairment in the elderly, but that the instruments for the assessment of depression differentiate poorly between patients with and without cognitive impairment. Furthermore, the distinction between dementia and pseudodementia, using the scale proposed by Wells, seems dubious. Additional research is needed in order to differentiate better between these two conditions, and to validate some instruments designed for the assessment of cognitive impairment in the elderly.

WHO-coordinated biological research on other mental disorders Other studies have dealt with the effectiveness of psychotropic medication; the largest of these have been the WHO-coordinated studies of the effects of psychotropic drugs in different populations (Sartorius, 1981). Anecdotal accounts and occasional reports in the literature seemed to indicate that populations living in settings with different climatic, nutritional and sociocultural conditions require significantly different dosages of common psychotropic drugs. To investigate this important hypothesis, WHO carried out double-blind collaborative studies on dose effectiveness and of the frequently used antidepressants and neuroleptic medicaments in several countries. A set of instruments for the assessment of the clinical conditions and their changes was produced, using some of the schedules mentioned in Chapter 4 as well as some newly developed techniques. The effectiveness of benzodiazepines was also examined in some of the centres participating in these investigations (Sethi et al, 1984; Morosov, 1986a). This clearly demonstrated the value of counselling and the superiority of the combined use of counselling and medication use over the use of medication alone. It also produced evidence about instruments used in the assessment of effects of treatment of mild mental disorders in different cultures. Other studies in this area include the investigation of the therapeutic ‘window’ of neuroleptics, and the effects of naloxone on schizophrenic and manic syndromes (Pickar et al, 1989).


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The growing awareness of the great public health importance of alcohol-related problems, ranging from cirrhosis to traffic accidents, as well as the testing of effective interventions, has revived WHO’s commitment to action in this field, including the specific aspects of biological research in this area. Alcohol dependence syndromes in different populations have been the object of a collaborative effort, involving some 10 institutions located in Ethiopia, Japan, Mexico, Morocco, Poland, Philippines, Russia, Serbia, Switzerland and The Netherlands (Ohmori et al, 1986; Yamashita et al, 1986). The aim of the study was to measure the isoenzyme activity of aldehyde dehydrogenase (ALDH-1, ALDH-2) and its correlation with alcohol dependence, particularly in Asian populations. Among the Japanese, inherited deficiency of ALDH-1 was found in 43% of the healthy subjects (50 out of 117), in 33% of the people with schizophrenia (27 out of 82), but in only 4% of alcohol-dependent persons (five out of 113). This study lends support to the notion that ALDH-1 deficiency (which produces the flushing syndrome) may inhibit the development of a drinking habit and alcohol dependence in some populations. In the area of specialist training, over the last 15 years WHO has organised 19 different training courses and seminars for specialists from developing countries, some of them in collaboration with CINP, NPA and local associations in the field of scientific information exchange (Bagadia et al, 1979; Ban & Odejide, 1980; Sethi et al, 1984; WHO 1985a,b). WHO has also spread scientific information to more than 150 countries. For this purpose it uses the leading scientific journals, newsletters and books on psychiatry and psychopharmacology (for examples, see references listed under ‘Other publications describing WHO activities in biological psychiatry’). One recent achievement in this field is the WHO Expert Series on Biological Psychiatry. The volumes in this series are prepared by specialists taking part in WHO’s programme on biological approaches to psychiatry. In 1992–93 the first three volumes were published with the following titles: Tardive Dyskinesia (Haag et al, 1992); Mental Disorders in HIV-1 Infection and AIDS (Maj et al, 1993); and Clinical Evaluation of Psychotropic Drugs for Psychiatric Disorders (Grof et al, 1993). The manuscripts for two other volumes, titled Anxiety and Clinical and Biological Aspects of Alcoholism, are now in press. The Division of Mental Health recently developed two new areas of work in keeping with WHO priorities: the implementation of noninvasive methods in biological psychiatry, and work on environmental factors affecting brain functions. Of particular note here are two large, new WHO projects on ‘Combined utilisation of an antidepressant (amitriptyline) and an antioxidant (gingko biloba) in the treatment of therapy-resistant depression’ and ‘Brain damage in utero’. The latter

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project alone involves plans to examine 7900 children and their families in areas exposed to radiation because of the Chernobyl accident.

References B AGADIA , V., E ISENBERG , L., O LATAWURA , M. O., et al (1979) Knowledge and technology needed for further development of mental health programmes. Neuropsychobiology, 5, 332–339. BAN , T. A. & O DEJIDE , A. O. (1980) Training in biological psychiatry: a WHO sponsored long-term programme. Health Communications and Informatics, 8, 96–100. BECH , P., L ANGER , S. Z., M ELLERUP , E., et al (1986a) Validity of imipramine platelet binding sites as a biological marker of endogenous depression. In Biological Psychiatry, pp. 1510–1512. Proceedings of the IVth World Congress of Biological Psychiatry, September 8–13, 1985, Philadelphia, USA. ——, G ASTPAR , M., M ENDLEWICZ , J., et al (1986b) WHO pilot study on the validity of the 3Himipramine platelet binding sites as a biological marker of endogenous depression. Clinical Neuropharmacology, 9 (Suppl. 4), 440–441. BECH , P., E PLOV , L., G ASTPAR , M., et al (1988) WHO pilot study on the validity of imipramine platelet binding receptor binding sites as a biological marker of endogenous depression. Pharmacopsychiatry, 21, 147–150. COPPEN , A., M ETCALFE , M., H ARWOOD , J., et al (1987) The dexamethasone suppression test in depression. A WHO Collaborative study. British Journal of Psychiatry, 150, 459–462. GASTPAR , M., N GO K HAC , T., G ILSDORF , U., et al (1986) Comparison of oral and intravenous treatment of depressive states: preliminary results of a WHO Collaborative Study. Clinical Neuropharmacology, 9 (Suppl. 4), 434–436. GASTPAR , M., G ILSDORF , M., A BOU -S ALEH , M. T., et al (1992) The dexamethasone suppression test in depression: a WHO collaborative study. Journal of Affective Disorders, 26, 17–24. GERSHON , E. S., M ENDLEWICZ , J., G ASTPAR , M., et al (1980) A collaborative study of genetic linkage of bipolar manic-depressive illness and red/green colour blindness. Acta Psychiatrica Scandinavica, 61, 319–338. G ROF , P., A KHTER , M.I., C AMPBELL , M., et al (1993) Clinical evaluation of psychotropic drugs for psychiatric disorders: principles and proposed guideline. WHO Expert Series on Biological Psychiatry, Vol 2. Bern: Hogrefe & Huber. H AAG , H., R UTHER , E. & H IPPIUS , H. (1992) Tardive dyskinesia. WHO Expert Series on Biological Psychiatry, Vol. 1. Bern: Hogrefe & Huber. M AJ , M., S TARACE , F. & S ARTORIUS , N. (1993) Mental disorders in HIV-1 infection and AIDS. WHO Expert Series in Biological Psychiatry, Vol. 5. Bern: Hogrefe & Huber. M ELLERUP , E. T., L ANGER , S. Z. & R AFAELSON , O. J. (1984) WHO multicentre studies: methodological problems exemplified by the imipramine binding site study. Clinical Neuropharmacology, 7 (Suppl. 1). M ENDLEWICZ , J. (1984) New trends in research on biological markers within the WHO network (chronobiology and suicide risk factors). Clinical Neuropharmacology, 7 (Suppl. 1). MENDLEWICZ , J. & K ERKHOFS , M. (1991) Sleep electroencephalography in depressive illness. British Journal of Psychiatry, 159, 503–509. MOROZOV , P. (1981) International collaboration on biological approaches to classification of mental disorders: viewpoint of the WHO. Biological Psychiatry, 16, 496–501. —— (1984) WHO collaborative activities in the field of biological psychiatry and psychopharmacology: 10 years of experience. Clinical Neuropharmacology, 7 (Suppl. 1). —— (1985a) Biological psychiatry in the developing world: problems and perspectives – WHO role. Biological Psychiatry, 20, 1519–1522.


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—— (1985b) WHO multicentre studies on biological psychiatry. Biological Psychiatry, 20, 1501–1503. —— (1986a) Biological psychiatry in the developing world: problems and perspectives: WHO role. In Biological Psychiatry, pp. 1501–1503. Proceedings of the IVth World Congress of Biological Psychiatry, September 8–13, 1985, Philadelphia, USA. —— (1986b) Transcultural aspects of classification of mental disorders. Pharmacopsychiatry, 19, 26–28. OHMORI , T., K OYAMA , T. & Y AMASHITA , I. (1986) WHO collaborative studies on biological basis of alcoholism: regional experience. In Biological Psychiatry, pp. 1501–1503. Proceedings of the IVth World Congress of Biological Psychiatry, September 8–13, 1985, Philadelphia, USA. PICKAR , D., B UNNEY , W. E. Jr., D OUILLET , P., et al (1989) Repeated naloxone administration in schizophrenia: a Phase II WHO study. Biological Psychiatry, 25, 440–448. S ARTORIUS , N. (1981) WHO-coordinated collaborative studies on the effects of psychopharmacological drugs in different populations. Modern Problems of Pharmacopsychiatry, 16, 83–94. SETHI , B. B., R ADOUCO T HOMAS , C. & G ASTPAR , M. (1984) The role of the training component and exchange of information in the WHO programme in biological psychiatry. Clinical Neuropharmacology, 7 (Suppl. 1). WHO (1985a) Report on the Training Seminar in Psychopharmacology of South East Asian Countries. Khaka, Bangladesh, October/November 1985. MNH/MEP/85.5. Geneva: World Health Organization. WHO (1985b) Report on the WHO Training Course in Psychopharmacology for East African Countries. Nairobi, Kenya, April 1985. MNH/MEP/02.2/85.1. Geneva: World Health Organization. YAMASHITA , L., O HMORI , T., K OYAMA , T., et al (1986) WHO collaborative study of alcoholism with reference to ethnic differences. Clinical Neuropharmacology, 9, 442–443.

Other publications describing WHO activities in biological psychiatry B AN , T., V ARTANIAN , F., S ARTORIUS , N., et al (1979) Identification of high-risk criteria in the framework of WHO collaborative research in major mental disorders. Progress in Neuropsychopharmacology, 3, 575–578. BULYZENOV , V., C HRISTEN , Y. & P RILIPKO , L. (Eds) (1990) Genetics Approaches in the Prevention of Mental Disorders. Berlin: Springer Verlag. BUNNEY , W. E. & V ARTANIAN , M. E. (1984) Prophylactic studies: new results and perspectives for the WHO programme. Clinical Neuropharmacology, 7 (Suppl. 1). H ARDING , T. & C HRUSCIEL , T. L. (1975) The use of psychotropic drugs in developing countries. Bulletin of the World Health Organization, 52. IENI , J. R., Z UKIN , S. R. & VAN P RAAG , H. M. (1984) Complex interactions of 3H-imipramine with platelet and brain binding sites: implications for clinical research. Clinical Neuropharmacology, 7 (Suppl. 1). KEMALI , D., M OROZOV , P. & T OFFANO , G. (Eds) (1984) New research strategies in biological psychiatry. Biological Psychiatry - New Prospects, 3. MOROZOV , P. (1981) Historical background of virological research in psychiatry and the role of WHO in the present stage of investigations. Biological Psychiatry, 16, 53–58. P ACKER , L., P RILIPKO , L. & C HRISTEN , Y. (eds) (1992) Free Radicals in the Brain: Aging Neurological and Mental Disorders. Berlin: Springer Verlag. S RAM , R. J., B ULYZENKOV , V., P RILIPKO , L., et al (eds) (1991) Ethical Issues of Molecular Genetics in Psychiatry. Berlin: Springer Verlag.

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The WHO neurosciences programme for the control of neurological disorders (1973–1986) C. L. BOLIS

Introduction Neurological disorders represent an important cause of disabilities and human suffering for individuals and their families, and hence to society. Many neurological disorders might be prevented, and for this reason, appropriate efforts to elucidate risk factors and to implement effective preventive measures are warranted. As a whole, neurological disorders have different origins: toxic, metabolic, genetic, infectious, immunological, traumatic, degenerative, nutritional or due to substance misuse. In developing countries, infectious (bacterial and viral) and parasitic disorders of the central and peripheral nervous systems represent a very serious problem. These diseases have come to appear even more alarming when their interference with immunopathological reactions has been gradually elucidated. Environmental toxins and malnutrition are also responsible for many neurological disorders. Research over the last decade has made it increasingly clear that even relatively mild degrees of nutritional deficiency – sufficient only to retard a child’s physical growth and development or to produce mild anaemia – can affect profoundly the cell-mediated immune processes. This, in turn, can affect the occurrence and the severity of many infectious neurological diseases as well as the response to vaccines for their control. 110

Neurosciences programme 111 Trauma and traffic accidents are also important causes of neurological disorders.

Public health priorities in neurology Among all neurological disorders, epilepsy has undoubtedly represented a priority for WHO’s action since the first years of the organisation’s life. Therefore, as early as 1954, WHO convened an expert committee on epilepsy to discuss the most viable preventive and intervention strategies to be launched at an international level in order to gradually control the magnitude and the severity of the problem. A dictionary of epilepsy was published, and several other activities in this field were started. Later, in 1969, WHO convened an international scientific group to discuss a programme on the control of neurological disorders and to define its priority areas. In the same period, the WHO Advisory Committee on Medical Research also recommended to the Director-General that increased attention be given to research in the neurological sciences. In order to support the development of activities in the overall field of neuroscience, an Expert Advisory Panel on Neurosciences was established in 1973; shortly after that event, the WHO neurosciences programme for the control of neurological disorders was established as part of the Division of Mental Health. The first WHO Consultation on Neurosciences was held in Geneva in August 1973. Participants reviewed knowledge and current research trends in the field, and made recommendations to the Director-General concerning prevention and control of neurological disorders. They also recommended the establishment of collaborating centres for research and training in the neuroscience field. Collaborating Centres (CCs) in Ibadan (Nigeria), Marseilles (France), Mexico City, Montreal (Canada), and Strasbourg (France) were designed shortly afterwards; in 1975–76, additional centres located in Bethesda (USA), in Moscow (USSR) and in Dakar (Senegal) were added. The second WHO Consultation on Neurosciences was held in Marseilles in November 1974. On that occasion priority areas were selected for the consideration of public health needs, with particular reference to developing countries. The third WHO Consultation on Neurosciences was held in April 1976 in Montreal (Canada). The cooperation between CCs in the field of epilepsy was reviewed, and research projects on cerebrovascular disorders were discussed and agreed upon.

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At the fourth WHO Consultation on Neurosciences, held in Abidjan in 1982, the Directors of the CCs reviewed the plans for collaborative research. One year later (1983), the Fifth WHO Consultation on Neurosciences was held in Florence (Italy), and participants stressed the importance of focusing on areas of major public health concern, such as epilepsy and stroke. In addition, much consideration was given to manpower development. The programme, during its development, took into account the results of studies on the basic mechanisms involved in the causation of neurological disorders in order to apply all possible measures of prevention and treatment. The major lines followed were: (1) Promotion of basic science research, which will give particular feedback information for applied clinical research. (2) Field research studies on neuroepidemiology in order to have information on the incidence, prevalence and distribution of neurological disorders in different parts of the world. Field studies in specific areas should make it possible to: (a) provide accurate statistics concerning the number of people affected by a particular disease in a selected area; (b) indicate whether the disease is increasing or decreasing in frequency; (c) identify areas of the cause of the world with a particularly high or low frequency of disease; (d) provide clues as to the cause of disease; (e) define factors that are important in predicting the outcome of disease; (f) measure the social and economic impact of disease; (g) evaluate the effectiveness of methods of treatment; and (h) forecast the needs for programmes and facilities to care for the people affected. These studies are fundamental to the better understanding of the dynamic distribution of neurological disorders and hence to their control. A WHO protocol has been developed for these field studies and suitable areas have been identified in Africa, South America, south-east Asia and some developed countries: the WHO Collaborating Centres for Research and Training in Neurosciences are of great help in this effort. (3) Field research studies in specific areas of neurology, such as epilepsy, neuropathies (toxic, metabolic, traumatic), neuroendocrinology and behaviour in aging (including Alzheimer’s disease and senile dementia), and cerebrovascular disorders,

Neurosciences programme 113 infectious disorders, and epilepsy. A protocol for community control of epilepsy was prepared and tested. (4) Implementation of training of medical personnel for the better application of knowledge for the prevention and treatment of neurological disorders, as well as the organisation of training courses in different regions. (5) Establishment of a two-year fellowship programme by WHO and the Fogarty Foundation for training in neurology (neuroepidemiology, neuropathy, basic neurosciences, neurology) for doctors mainly from Africa, south-east Asia, and South America; so far 25 fellowships have been awarded. (6) Diffusion of information through study group reports and other documents, organisation of international conferences on specific subjects, and co-sponsoring of international meetings in neurosciences in different parts of the world.

Conclusions The programme for the control of neurological disorders has been very active and has organised over the years a number of relevant scientific events, including four study groups, three round tables and 30 WHO scientific meetings in the field of peripheral neuropathy, diabetic and traumatic neuroendocrinology and behaviour in aging, an international conference on neural aging, basic and clinical aspects and neuroepidemiology and an international symposium on cerebral ischaemia. Thirty reports have been prepared for the different activities and assistance provided in the revision of the International Classification of Diseases and the adaptation of ICD–9 to neurology.

Publications associated with WHO programmes and activities in neurosciences and neurology WHO (1978) Cerebrovascular Disorders: A Clinical and Research Classification. WHO Offset Publication No. 43. Geneva: WHO. —— (1978) The Application of Advances in Neurosciences for the Control of Neurological Disorders. Technical Report series No. 629. Geneva: WHO. —— (1979) Control of Brain and Nerve Diseases. A World-Wide Challenge. Geneva: WHO —— (1979) Cerebrovascular Disorders and Stroke (eds M. Goldstein, C. L. Bolis & C. Fieschi). New York: Raven Press. —— (1980) Peripheral Neuropathies. Technical Report Series No. 654. Geneva: WHO. —— (1981) Neuronal Aging and its Implications in Human Neurological Pathology. Technical Report Series No. 665. Geneva: WHO.

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—— (1982) Neural Aging and its Implications in Human Neurological Pathology, Vol. 18 (eds R. D. Terry, C. L. Bolis & G. Toffano). New York: Raven Press. —— (1982) International Conference on Peripheral Neuropathies (eds S. Refsum, C. L. Bolis & A. Portera Sanchez). Rome: Excerpta Medica. —— (1983) Neuroplasticity and Repair in the Central Nervous System: Implications for Health Care. WHO Offset Publication No. 73. Geneva: WHO. —— (1984) Summaries presented at the round table on motor neuron system disorders. African Journal of Neurological Sciences, I, 21–27. —— (1984) Proceedings of Training Course on Peripheral Neuropathies at Marseilles. March 2– 3, 1984. Geneva: WHO. —— (1985) Central Nervous System Plasticity and Repair (eds A. Bignami, F. E. Bloom, C. L. Bolis, et al). New York: Raven Press.

Publications associated with WHO activities in neuroepidemiology BOLIS , C. L. (1981) Global Neuroepidemiology: Accomplishments of the World Health Organization. Rome: Excerpta Medica. CHUNG -C HENG , W., X UE -M ING , C., S HI -C HUO , L., et al (1983) Epidemiology of cerebrovascular disease in an urban community of Beijing, People’s Republic of China. Neuroepidemiology, 2, 121–134. ——, S CHOENBERG , B. S., S HI -C HUO , L., et al (1984) Epidemiology of epilepsy and brain injury in urban areas of the People’s Republic of China. Annals of Neurology, 16, 120. CRUZ , M. E., T APIA , D., P ROANO , J., et al (1984) Prevalencia de desordenes neurologicos en Quiroga (Prov. Imbabura). Revista Ecuatoriana de Medicina, XX (2), 77–91. ——, S CHOENBERG , B. S., B ARBERIS , P., et al (1985) Feasibility of a field research protocol to measure the prevalence of common neurologic diseases: Quiroga and Galapagos Islands, Ecuador. Neuroepidemiology, 4 (2), 108–112. ——, ——, R UALES , J., et al (1985) Pilot study to detect neurologic disease in Ecuador among a population with a high prevalence of endemic goiter. Neuroepidemiology, 4, 108–116. OSUNTOKUN , B. O., S CHOENBERG , B. S., N OTTIDGE , V., et al (1982) Migraine headache in a rural community in Nigeria: Results of a pilot study. Neuroepidemiology, 1, 31–39. ——, ——, ——, et al (1982) Research protocol for measuring the prevalence of neurologic disorders in developing countries: Results of a pilot study in Nigeria. Neuroepidemiology, 1 (3), 143–153. ——, A DEUJA , A. O. G., N OTTIDGE , V., et al (1987) Prevalence of the epilepsies in Nigerian Africans: A community based study. Epilepsia, 28, 272–279. ——, ——, S CHOENBERG , B. S., et al (1987) Neurological disorders in Nigerian Africans: A community based study. Acta Neurologica Scandinavica, 75, 13–21. MORGANTE, L., GRIGOLETTO, F., MENEGHINI, F., et al (1989) Neuroepidemiology survey on Sicilian population: A feasibility study. Neuroepidemiology, 8, 214–220. SACHS , H., S EVILLA , F., B ARBERIS , P., et al (1985) Headache in the rural village of Quiroga, Ecuador. Headache, 25, 190–193. S HI -C HUO , L., S CHOENBERG , B. S., C HUNG -C HENG , W., et al (1984) Cerebrovascular disease in the People’s Republic of China: Epidemiologic and clinical features. Neurology, 34 (Suppl. I), 243. ——, ——, ——, et al (1985) Cerebrovascular disease (CVD) in the People’s Republic of China: Epidemiologic and clinical features. Neurology, 35, 1708–1713. SCHOENBERG , B. S., A NDERSON , D., H AERER , A. F., et al (1981) A Strategy for Neuroepidemiologic Studies in Developing Countries. Rome: Excerpta Medica.

Psychosocial aspects of health

Part III. Programmes and policies for specific disorders in the mental health field

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WHO’s activities related to psychosocial aspects of health (including child and adolescent health and development) PHILIP GRAHAM and JOHN ORLEY

Introduction The WHO Division of Mental Health has undertaken a broad range of activities related to psychosocial aspects of health across the lifespan. These activities have always been considered as an important contribution to provide mental health inputs into all aspects of health care. The aim of this chapter is to describe the main activities carried out by the Division in the areas of (i) psychosocial development of children and adolescents, (ii) the evaluation of health-related quality of life in people in contact with health services, and (iii) the training of medical students with regard to behavioural science and specific behavioural skills.

Psychosocial development of children and adolescents Over the past two decades, in nation after nation, there has been a growing awareness of the importance of policies and programmes that are specifically aimed at improving the lives of children. In parallel to this important development, there has also been a growing awareness of the importance that a variety of psychosocial factors play for the overall health of children. WHO has been at the forefront of this challenge and has launched and stimulated several programmes 117

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in the field of child health at international and country level, in the context of the target of Health for All by the Year 2000. From its earliest years, WHO has considered the mental health of children a priority area. In 1948 the United Nations commissioned a study of the effects of homelessness on children, and WHO offered to consider the mental health aspects of this problem. With this in mind, in 1950, John Bowlby, a then relatively unknown British child psychiatrist, was appointed as a WHO consultant. He visited several European countries and the USA to carry out a study of children living in institutions of different types. His conclusions were published in a WHO monograph (Bowlby, 1951). They laid emphasis on the fact that care in a family is the only appropriate care that should be provided for children. This meant, for instance, that when parental care irretrievably broke down, adoption into another family should be arranged as soon as possible. Long-term family foster-care was seen as a less satisfactory arrangement, but better than care in a children’s home. Emotional deprivation and frequent separations were seen as a major contribution to delinquency and to the development of psychiatric disorder. In passing, the practice of separating babies from their mothers at the time of birth in hospital was roundly condemned in this report. The fact that his findings now seem rather banal is a tribute to the influence of Bowlby’s ideas on social and health policies concerning those children whose parents are unable to provide adequate care, and on the welfare of children in hospital. They are now so widely accepted as to appear self-evident. The monograph is surely one of WHO’s most successful books. It has sold over 450 000 copies and been translated into at least ten languages. Although he possibly underplayed the importance of fathers, and perhaps slightly overplayed the significance of separation, nevertheless, by the standards of his day, Bowlby wrote a humane, scientifically excellent document. Sometimes his ideas were misinterpreted and led to the unnecessary closure of day nurseries and to guilt in mothers who left their children with quite satisfactory substitutes in order to go out to work. But, overall, Bowlby’s work led to great improvements in the care of children in hospitals and other institutions.

Planning for child mental health From 1951 there was a long, 25-year gap before WHO activities in the field of child mental health became significant once again. During this time, the WHO focus on the major causes of childhood mortality throughout the world meant that child mental health was


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given little priority. Dr Sartorius, as Director of the Division of Mental Health, realised in the mid-1970s that this was unacceptable. First, shortage of necessary food and the resources to immunise children against disease were not usually the main causes of malnutrition and infectious disease. What lay behind these killing diseases were poor child care, lack of education, inappropriate dietary beliefs, and low motivation to mount immunisation campaigns. Further, the notion that child mental health was protected in societies in which extended family rather than nuclear family arrangements were the rule was inaccurate. Preliminary work, even at that time, suggested that the prevalence of psychiatric disorders in children living in extended families was very little different from that occurring in children living in nuclear families (Graham, 1979). In 1976, WHO convened an expert committee on child mental health and psychosocial development and its report was published a year later (WHO, 1977). Once again this report is widely regarded as a landmark in the identification of issues relevant to child mental health worldwide and in the planning of child mental health services, especially in countries where relevant professional expertise is sparse. Following on Bowlby’s earlier findings, the Committee pointed to the paramount importance of continuity of parentfigures. Parents should, for example, have unlimited access to their children in hospital, and early adoption should occur when parents are unable to look after their children. Prevention programmes in this field should be mounted and monitored. Governments should develop child mental health treatment resources at the community level. An epidemiological approach to the problem was encouraged, especially as by this time it had been well demonstrated that reliable and valid measures existed to define and identify ‘cases’ of disorder (Rutter et al, 1970). Governments were also encouraged to develop national policies to promote child mental health, and the formulation of these policies should involve not just health departments, but those involved in juvenile justice, education and social welfare. Following the publication of this report, the division obtained resources to promote the development of national plans for child mental health in different countries. One of the authors of this chapter (PG) was commissioned to attend regional conferences and to visit individual countries with this in mind. In order to achieve some standardisation of approach, a national case study format was developed (Sartorius & Graham, 1984). A set of guidelines was proposed to describe the type and amount of information to be collected: frequency and types of child mental health problems in the countries concerned, their main causes, children’s reactions to stress, sociocultural and environmental factors (such as the role of

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women, average family size, child rearing beliefs and practices), legislation, and existing approaches and services for prevention and treatment. In each country a small multi-disciplinary group was convened to formulate this information and make recommendations to government departments and to the relevant professional bodies. The impact of this document was inevitably variable, but in some countries, e.g. Greece and Sri Lanka, the impact of the document was considerable.

Bio-behavioural approaches to major causes of mortality and morbidity From the time of the foundation of the UN following the Second World War, it has been clear to those charged with the responsibility for taking a global perspective on child health that the major causes of death and disability on a worldwide scale are malnutrition and infection. The last decades have seen significant achievements in child health at an international level, as shown by a number of commonly agreed health indicators; these achievements have been highlighted in the 1996 World Health Report (WHO, 1996) and in the 1996 UNICEF Report on the State of the World’s Children (UNICEF, 1996). At the same time, these reports underline several problems, still unresolved, which are of major concern for child health in most countries and can prevent the optimum development of the infant population. With regard to child mortality rates, defined as the probability of dying by the age of five years, the global average in 1995 was 81.7 per 1000 live births. However, large differences were evident between various areas of the world: the child mortality rate was 8.5 per 1000 in the industrialised world, 90.6 in the developing world and 155.5 in the least developed nations. More than 11 million such deaths occur in the developing world: of them, nine million have been attributed to infectious diseases, and about 25% of these might be prevented by immunisation. Even in the poorer areas of the world, however, child mortality rates have been improving significantly: in 1960, in developing countries, the infant mortality rate was 138 per 1000 births and overall 216 children per 1000 died before the age of 5; by 1995, these rates were more than halved, with an infant mortality rate of 67 and an under-5 mortality rate of 100. Immunisation against six vaccine-preventable diseases (diphtheria, pertussis, tetanus, measles, tuberculosis and poliomyelitis), undertaken with intensive support from WHO, UNICEF and the international


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community, has saved millions of children annually from death and disability. While the battle must continue against preventable child mortality, the emphasis is now turning to ways to enhance the physical and mental development of the majority who in fact survive infancy; or as Meyers (1992) has eloquently put it, of “The twelve [out of thirteen] who survive”. In parallel with these developments, there have been other major international initiatives which influence child health, such as the 1989 Convention on the Rights of the Child. As of September 1995, as many as 179 countries had ratified the Convention, committing themselves to “ensure that all children have the right to develop physically and mentally to their full potential, to express their opinions freely, and to be protected against all forms of abuse and exploitation”. Although poverty and inadequate resources are important factors associated with child mortality and poor child development, nevertheless there are great variabilities between nations of similar economic level, as well as within nations. The causes of such variability are many. Governments vary in their commitment to child health, maternal education, and the efficient structures of health promotion and care delivery. Within the same locality within a single country, with food availability at a uniform level, some young children will become malnourished and others will not. Children with isolated, depressed parents, lacking necessary health information, possessing inaccurate beliefs about the nutritional value of different foods and low in child care skills are obviously at much greater risk. Several WHO programmes in collaboration with UNICEF,have struggled to identify bio-behavioural causes of the major killing and disabling childhood diseases and to put forward remedies. Dr Norman Sartorius and Dr David Hamburg carried out a review of bio-behavioural interventions in various diseases and disorders throughout the world (Hamburg & Sartorius, 1989), as part of a valuable initiative within WHO on biobehavioural science applications to health care, funded by the Carnegie Corporation. This was carried out within WHO’s programme on Psychosocial and Behavioural Factors in Human Health and Development, which formed a crucial part of the activities of the Division of Mental Health when it was founded in 1976 under the leadership of Dr Sartorius.

Health promotion in early childhood As already set out, in the area of early childhood, the health sector has generally put most (if not all) of its efforts into promoting and maintaining the physical health of children, emphasising the safe

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delivery of babies, breast feeding, immunisation against diseases and the importance of a nutritious diet. The health sector, however, has paid much less attention to the enhancement of psychosocial development of children which includes mental, emotional as well as social growth. The health sector has done very little to ensure that children get what might be called good ‘psychosocial nutrition’ as well as good physical nutrition. Mother is the most important person in a baby’s life for both its physical as well as its psychosocial care and growth and the mother– infant relationship is the most vital formative relationship for the child, as already stressed in the landmark study by Bowlby. A mother’s expression of love towards her baby and her conversation with it are of utmost importance for its mental development. From the very first moments of life, a baby begins interacting with its mother and this continues over the years. Infants send out messages to the mothers, who also need to respond appropriately. Babies, in fact, are positively distressed when their mothers do not respond to their initiatives (Tronick et al, 1978; Murray & Trevarthen, 1985). In most cases such ‘conversations’ happen naturally, because mothers and babies are biologically programmed to start such conversations (Blehar et al, 1977), just as mothers and babies are biologically programmed for breast feeding. Nevertheless, situations arise which make it difficult for this communication to occur, and some help has to be provided, just as some mothers need help to get breast feeding started. One approach is to create an atmosphere in which such communication is more likely to occur by facilitating environments and opportunities for good psychosocial interaction between mothers and babies. There are however occasions when this communication, and the establishment of the relationship, suffers. It may be that a mother does not have the time to give to her baby, perhaps because she has too many children, too closely spaced, or too many other tasks with insufficient support. Some mothers may be uncertain about what to do or how to respond to their children despite the biological pressures to do so. Having their own mother or older women to guide them would be useful, but with the break down of traditional family patterns some young mothers do not even have that. Other mothers are depressed and do not have the energy or motivation to respond to the biological imperatives (Murray et al, 1996). There might too be features in the child that in some way inhibit the interaction with the mother. A low birth weight baby in an incubator, for instance, cannot interact so easily with its mother (Masi & Scott, 1983). Other babies and children may have motor and sensory


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disabilities (e.g. blindness) preventing them from communicating with their mothers or preventing them from receiving communications from their mothers. These are just problems in the natural family, but in the case of children in institutions or orphanages even the biological pressures on the caretaker will be missing. The staff here often need help in responding correctly to the communications from the children. It is, unfortunately, too easy for the caretaker to be like a gardener under these circumstances, treating children like plants to be watered, fed and treated for diseases, rather than as people who need human interaction. In particular, day care for children should never be an opportunity for parking children, like cars in a garage or parking lot. Day care, even for very young infants, needs to provide the opportunity for interactions with the caregivers which will enrich and facilitate the child’s development, and the WHO Mental Health Programme has produced a checklist of items that enable child day care facilities to monitor themselves, to ensure that they are providing good quality psychosocial as well as physical care (WHO, 1990). In response to the need for enhancing this early caretaking by mothers (and others), the WHO Mental Health Programme has, out of the bio-behavioural science programme funded by the Carnegie Corporation, developed a project which is guided by the recent scientific advances that have taken place in this field (WHO, 1993a).

Mental and emotional problems in children In the infant and young child, feeding and sleeping problems are common. Physical and emotional abuse, as well as non-organic failure to thrive, also occur. In school-aged children, learning difficulties may become more evident, while in adolescents, in many countries, violent deaths from suicide, attempted suicide, homicide and road traffic accidents are major reasons for contacts with health services, hospital admissions and death. Throughout childhood and adolescence, medically undiagnosed physical symptomatology is a frequent reason for attending primary and secondary health care facilities. Primary health care workers, however, whether they are doctors or nurses, are often poorly trained to assess and treat these very common symptoms for which no physical cause can be identified. If, as turns out to be the case, about a third of those attending for primary and secondary health care in developed countries (Garralda & Bailey, 1986) and a similar proportion for primary care in Third World countries present with non-organically determined physical

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symptomatology, it is clearly important for appropriate guidelines for management and training to be made available. In a WHO-sponsored study, Giel et al (1981) demonstrated in their study of the frequency of mental disorders in those attending at primary care facilities in four economically underdeveloped countries (Sudan, Philippines, Colombia and India) that between 12% and 29% of children aged 5 to 15 years showed mental health problems. The types of disorder identified, in these developing countries, were no different from those encountered in industrialised countries. There was no problem in identifying these disorders – mothers readily talked about the symptoms if they were directly asked. Nevertheless, only between one in ten and one in five (10–20%) of the disorders were actually identified by the primary health care workers themselves. The lack of training in the identification of childhood mental disorders, not only for primary health care workers, but also for teachers and those working in residential facilities for children, led to various training initiatives by WHO, many undertaken by the Division of Mental Health. This exercise for the South East Asian Regional Office resulted in the production of four manuals to help those in direct contact with children, such as teachers and primary health care workers, with identification and first line management (WHO, 1982) and a further one for Primary Care Physicians, on recognising and managing children with functional complaints (Nikapota, 1987). Health promotion in adolescence With regard to school-age children, WHO has recently emphasised a programme of life skills education in schools. This programme aims to provide, within the school curriculum, a programme to enhance psychosocial competencies or life skills in school children. Life skills is used to refer to very basic, rather generic skills, such as: (i) decision making and problem solving skills; (ii) creative thinking and critical thinking; (iii) communication and other interpersonal skills; (iv) self-awareness and empathic skills; and (v) coping with stress and coping with emotions. Such skills are not only important in promoting the mental well-being of the children, but they enable children to take more responsibility for their lives and to feel more effective. The learning of such skills, however, is also important because this acquisition helps children to choose healthier behaviours, and healthier life styles, avoiding health damaging behaviours such as smoking, drug taking or unprotected sex (Glynn, 1989; Perry & Kelder, 1992; Kirby et al, 1994). Providing information


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alone about dangers to health seems ineffective in dissuading children from carrying out such behaviours. On the contrary, messages about healthy behaviours need to be embedded in a broader framework of providing skills for a generally healthier and more balanced mental life. The learning of such skills has to begin early in life and should not be started at the end of a school career, for instance, by just providing communication skills to older teenagers in order to promote more responsible sexual behaviour or condom use. The aim of a life skills education programme, therefore, is to introduce the teaching of communication skills at the appropriate level for children of each age when they have an opportunity to practise the skills right away. Communication skills for younger children will involve those related to safety and the prevention of child abuse or bullying. For slightly older children, similar communication skills can be taught but this time focused on such issues as smoking and cigarette refusal, while still later one might consider communication skills in relation to alcohol and drug misuse. By this time children will have a much better idea about communication skills and the application of these to their lives. It therefore becomes much more natural for them to learn, at a later age, the communication skills that are appropriate for avoiding unwanted sex or negotiating appropriate sex or condom use, if that is what the young person chooses. The process might be likened to the learning of mathematics. At younger ages one learns the simple processes of adding, subtraction and multiplication. As one gets older one learns to apply these processes in the more complicated tasks related to algebra and geometry, while finally in the last years of school some will apply the same mathematical skills but in yet more complicated ways to problems of calculus. Just as one cannot rush in and teach calculus at the age of 17, without having had a period of developing simpler mathematical skills, so it is that the process of learning life skills should be one which is developmental throughout schooling. The learning of life skills, however, cannot take place in the typical classroom setting in which students receive knowledge passively from their teachers. The WHO approach therefore advocates that the children participate much more actively in the process of learning the skills, and for this reason the life skills education process requires much more participatory and cooperative learning. It should also involve providing the opportunities for the practice of these skills outside the classroom, in community activities as well as involving parents, so that the process can be continued and reinforced at home. This may be a more strenuous activity, particularly for teachers who have traditionally not taught in this way. Nevertheless experience seems to indicate that the teachers and students who participate in such life

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skills education find it enjoyable and rewarding and there are many reports of positive outcomes to this process. School mental health Many of the same principles that are applied to early childhood can also be continued in the school years, using the school system as a means of enhancing mental and social health in the pupils. Yet the question has to be asked as to how much schools actually do promote psychosocial development or improve mental health and well-being, in addition to providing or increasing knowledge. Schools need to provide a psychosocially enriching environment for the children. If health is a state of complete physical, mental and social well-being (and not just the absence of disease), schools must be places which can promote such health and well-being. But for some children, unfortunately, schools provide a psychosocially damaging environment. Prompted by this concern, the WHO Mental Health Programme has produced a checklist of steps to become a ‘child friendly school’ which is more promoting of mental health (WHO, 1997a). This forms part of WHO’s overall Health Promoting Schools initiative. To take an example, bullying is highly prevalent in many schools. It is demoralising for those being bullied, it can lead to an atmosphere of fear throughout the school and it surely has an adverse effect on the social development of the perpetrators. One research study in the United Kingdom found that more than 20% of children reported being bullied in school (Boulton & Underwood, 1992) and another has reported that an even greater number feared being bullied, even if they themselves were not victims (School Health Education Unit, 1996). Effective programmes to prevent bullying have been developed, largely depending on having a strictly enforced policy against bullying, making it quite clear to all students, teachers and parents that bullying will not be tolerated, and then training teachers how to handle it. Much bullying takes place because staff and school monitors turn a blind eye when they see it occurring. Children also need to learn to take responsibility for themselves and for their own health and well-being. It is, after all, they themselves who will make the decisions about whether they will smoke, whether they will have sex, whether they will take drugs or how much they will drink. All too often, however, children are encouraged to take a passive dependent position, where the teacher is the expert. The school and home, however, have to provide opportunities for creating selfconfidence in children, self-esteem, and a belief in their own efficacy.


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The WHO Quality of Life Project If health is a state of physical, mental and social well-being, then the health services should have reliable and valid ways of assessing that well-being. Although there are ways of assessing mental pathology and disability, it is only recently that measures of well-being have started to be used within the health sector. The WHO Quality of Life instrument (WHOQOL) for assessing quality of life in health care settings has been developed in 15 centres around the world, in Europe, Asia, Africa, North America and Latin America (WHO, 1997b). Quality of Life has been defined by the WHOQOL Group as individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept incorporating in a complex way people’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationships to salient features of the environment. Multi-dimensionality is included in the sense that a number of different aspects of people’s life should be assessed, in order to have an idea as to its quality; it is not enough just to look at physical functioning alone, or social functioning alone, or indeed at any other single aspect. Therefore items exploring the physical domain, the psychological domain, level of independence, social relationships, the environment and personal beliefs have been included in this new instrument. Apart from its multi-dimensionality, Quality of Life was also defined as being highly subjective; that is, the project was interested in how the subjects themselves view their position in life. This is more to do with how satisfied the subjects are with the defined aspects of their life, or how bothered they are by any problems. It cannot for instance be said that having just a few hours sleep each night has adverse consequences for a person’s Quality of Life. It is necessary to know how satisfied a person is with his or her sleep, regardless of how many hours of sleep there are. In addition to Quality of Life assessment, there is of course a place for assessing signs and symptoms in making diagnoses and evaluating interventions, and there is a place too for assessing disability. The leadership role of the WHO Mental Health Programme in those areas is well documented. An assessment of Quality of Life adds just a further dimension which should not replace the other measures, but should complement the other assessments. It is, moreover, more clientcentred, allowing the patients or clients to say how they feel about what is happening to them.

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The WHOQOL now exists in a 100-item version, covering 24 different facets of life. It has been field tested in a number of centres around the world, and there are now some 30 different national versions of the instrument. The pilot testing of the WHOQOL-100 has made possible tests of the universality of the concept of QOL in very different cultures and socio-economic settings around the world (The WHOQOL Group, 1998). An important finding of the WHOQOL study from 15 centres world-wide provides strong support for the possibility that there are universal aspects of quality of life that are common to different cultures. For instance, support for such cross-cultural universality can be deduced from the strong similarity of the QOL construct across different cultures, using structural equation modelling. Such results, however, do not mean that QOL is the same across different cultures and socio-economic settings. For instance, the lower satisfaction with financial resources, quality of home environment and the physical environment was found in centres in economically poor countries.

Behavioural Science Learning Modules Since the early 1980s, a number of efforts were made by the WHO Division of Mental Health to enhance the application of behavioural science principles to health care, and in pursuit of this to improve the teaching of behavioural science to health workers. More recently the Mental Health Programme focused specifically on training that is aimed at improving the effectiveness of health workers’ behaviour, or modifying the behaviour of the recipients of health care, to increase their level of health. As a first step in this, the Programme has recognised the importance of good communication between health workers and their patients or clients. The skills for such communication should be taught to students in all the health professions. As a start in this field, the Programme has produced a document on doctor–patient interaction and communication, although the principles set out are applicable to all health workers, not just doctors (WHO, 1993b). In addition, WHO has produced a number of Learning Modules aimed again primarily at physicians but more widely applicable, concerning specific aspects of communication, such as preparing patients for surgery, or communicating bad news: telling patients they have an incurable and potentially fatal disease, or telling parents about a baby who may have been born with an abnormality. The aim of these modules is to promote the mental health and well-being of patients within any area of health care, by teaching health workers to be sensitive to their patients’ mental health needs and to provide sympathetic and useful


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communication. In the case of preparing patients psychologically for surgery, this is known to reduce the amount of time that patients spend post-operatively in hospital, and so can be an attractive intervention from the point of view of the hospital cost reduction. However, the improvement of the patient’s mental well-being is a proper end in its own right and such interventions should still be carried out even if they could not be justified in this way for financial reasons. The eight modules produced so far form part of a series of Behavioural Science Learning Modules produced by the Division of Mental Health (WHO, 1993c). By behavioural science, it is meant looking both at health worker behaviour, including the teaching of skills to health workers (e.g. communication skills), and the behaviour of patients as it is relevant to prevention or to the management of a condition. Behavioural science in this context thus includes consideration of (a) behaviours of people which should be influenced in order to improve their health and (b) behaviours to be prevented because they have a demonstrable adverse influence on health (e.g. smoking, risky sexual behaviours). Modules on these latter topics are planned in the future. For the moment, the modules are aimed at medical students who seldom get out of the hospital and its clinics and into the community. The modules have therefore concentrated rather on dealing with more clinical material and have focused on behavioural interventions for hypertension, back pain, headache and insomnia, in order to convey to the students that pills, surgery and physical medicine are not the only solution to medical problems.

Conclusions Following John Bowlby’s contribution in the early 1950s, there was a long, fallow period within WHO in which child mental health and mental disorders were relatively neglected. The appointment of Norman Sartorius as Director of the Division of Mental Health led to major advances in this field. In particular, guidelines were given to national governments on ways in which child mental health services might be developed on a sound epidemiological and scientific basis. Significant contributions were made to the establishment of biobehavioural interventions for the major causes of childhood mortality and morbidity throughout the world, and significant advances were made in establishing the need for better care for child mental health disorders at primary level. At the same time, projects were initiated, targeting other areas related to psychosocial aspects of health. In particular, a reliable methodology has been devised to assess the quality of life of subjects

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coming in contact with health services, and the instruments designed in the framework of this project are likely to become the standard in this area. Many other projects were carried out within the framework of the programme on Psychosocial and Behavioural Factors in Human Health and Development, and they continue as an important part of WHO’s Mental Health Programme.

References BLEHAR , M. C., L IEBERMAN , A. F. & A INSWORTH , M. D. S. (1977) Early face–face interaction and its relation to later infant mother attachment. Child Development, 48, 182–194. B OULTON , M. J. & U NDERWOOD , K. (1992) Bully–victim problems among middle school children. British Journal of Psychiatry, 62, 73–87. BOWLBY , J. (1951) Maternal Care and Mental Health. World Health Organization, Monograph Series No. 2. Geneva: World Health Organization. GARRALDA , M. E. & B AILEY , D. (1986) Children with psychiatric disorders in primary care. Journal of Child Psychology and Psychiatry, 27, 611–624. GIEL , R., DE A RANGO , M. V., C LIMENT , C. E., et al (1981) Child mental disorders in primary health care: results of observations in four developing countries. Pediatrics, 68, 677– 683. GLYNN, T. J. (1989) Essential elements of school based smoking prevention programs. Journal of School Health, 59, 181–189. GRAHAM, P. J. (1979) Epidemiological issues and child psychiatry. International Journal of Mental Health, 7, 18–23. HAMBURG, D. & SARTORIUS, N. (eds) (1989) Health & Behaviour: Selected Perspectives. Cambridge: Cambridge University Press. KIRBY , D., S HORT , L., C OLLINS , J., et al (1994) School based programs to reduce sexual risk behaviours: A review of effectiveness. Journal of Public Health Reports, 19, 339–360. M ASI , W. S. & S COTT , K. G. (1983) Preterm and Full term infants’ visual responses to mothers’ and strangers’ faces. In Infants Born at Risk (eds T. Field & A. Sostek). New York: Grune & Stratton. MEYERS , R. (1992) The Twelve Who Survive. London: Routledge. M URRAY , L. & T REVARTHEN , C. B. (1985) Emotional regulation of interactions between two month olds and their mothers. In Social Perceptions in Infants (eds T. M. Field & N. A. Fox), pp. 177–197. Norwood, NJ: Abex. ——, STANLEY, C., HOOPER, R., et al (1996) The role of infant factors in postnatal depression and mother–infant interactions. Developmental Medicine and Child Neurology, 38, 109–119. NIKAPOTA , A. D. (1987) Recognition and Management of Children with Functional Complaints (Psychosocial Problems, Ill-defined Somatic Complaints) – A Training Package for the Primary Care Physician. SEA/Ment/93. New Delhi: WHO Regional Office for the South-East. PERRY , C. L. & K ELDER , S. H. (1992) Models of effective prevention. Journal of Adolescent Health, 13, 355–363. RUTTER , M. (1989) Child psychiatric disorders in ICD–10. Journal of Child Psychology and Psychiatry, 30, 23–51. ——, T IZARD , J. & W HITMORE , K. (eds) (1970) Education, Health and Behaviour. London: Longmans. SARTORIUS , N. & G RAHAM , P. (1984) Child Mental Health: Experience of eight countries. WHO Chronicles, 38, 208–211. SCHOOL H EALTH E DUCATION U NIT (1996) Bully Off. Exeter: University of Exeter.


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T RONICK , E. Z., A LS , H., A DAMSON , L., et al (1978) The infant’s response to entrapment between contradictory messages in face–face interaction. Journal of the American Academy of Child Psychiatry, 17, 1–13. UNICEF (1996) The State of the World’s Children. New York: UNICEF. WHO (1977) Child Mental Health and Psychosocial Development. Technical Report Series 613. Geneva: World Health Organization. —— (1982) Child Mental Health. Manuals for primary health care physicians, primary health care workers, teachers and workers in children’s homes. SEA/Ment/65-68. Delhi: WHO Regional Office for the South-East. —— (1990) WHO Child Care Facility Schedule – With User’s Manual. WHO/MNH/PSF/90.3. Geneva: World Health Organization. —— (1993a) Improving the Psychosocial Development of Children – Programmes for Enriching their Human Environment. MNH/PSF/93.6. Geneva: World Health Organization. —— (1993b) Doctor-Patient Interaction and Communication. WHO/MNH/PSF/93.11. Geneva: World Health Organization. —— (1993c) Behavioural Science Learning Modules. WHO/MNH/PSF/93.2.A-H. Geneva: World Health Organization. —— (1996) World Health Report. Fighting Disease Fostering Development. Geneva: World Health Organization. —— (1997a) ‘Child-Friendly Schools’ Initiative. MNH/PSF/97.1. Geneva: World Health Organization. —— (1997b) WHOQOL – Measuring Quality of Life. WHO/MSA/MNH/PSF/97.4. Geneva: World Health Organization. The WHOQOL Group (1998) The World Health Organization Quality of Life Assessment (WHOQOL): Development and general psychometric properties. Social Science and Medicine, 45, 1569–1585.

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10 Mental disorders and health in the elderly A. S. HENDERSON

Introduction In conducting its programme over the last quarter of a century, the Division of Mental Health has been consistently aware of its responsibilities to the world’s elderly, to their mental health, to their well-being, and to those in the wider community who are so directly affected by the expansion in their numbers. This expansion is unprecedented in the two million years of our species’ evolutionary history. UN population data show that there will be some 423 million persons aged 65 and over by the year 2000. Jorm et al (1988) have prepared graphs to show some of the global consequences of this demographic change: their calculations show the per cent increase in the world population, the increase in the elderly, and the increase in the numbers of persons who will suffer from a dementia. Both the demented and the elderly will have a greater increase than the general population, and in many developed countries, such as Japan, Australia, Bulgaria, Canada, Finland, Greece, Italy, New Zealand, Portugal, Spain, and Sweden, the prevalence of dementia will increase more rapidly than the elderly population.

WHO’s work for the health of the elderly The Division’s work with the elderly began in the 1950s, and it is most salutary to read the Sixth Report of the Expert Committee on Mental Health, which was addressed to ‘Health Problems of Aging and the Aged’ (WHO, 1959). Prepared nearly 35 years ago, that document addresses issues that continue to be at the forefront of our attention: 132

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the organization of geriatric services within psychiatry and within geriatric medicine; the need to train professionals in the field; and the critical need for further research. These issues were again the principal components of the Report from the WHO Scientific Group on Psychogeriatrics in 1972 (WHO, 1972), and the paper entitled Psychogeriatric Care in the Community (WHO, 1979), published as part of the series ‘Public Health in Europe’. One influential event was publication of the Technical Report of the WHO Scientific Group on Senile Dementia, which had met in Paris in 1983 to grapple with some fundamental issues on the epidemiology, neuropathology and treatment of the dementias. This led to the publication Dementia in Later Life: Research and Action (WHO, 1986). Close on the heels of that came the book entitled Mental Health in the Elderly. A Review of the Present State of Research, edited by Häfner et al (1986). This followed a scientific meeting held at the Central Institute of Mental Health in Mannheim, in collaboration with Geneva’s Division of Mental Health. In 1986, Hovaguimian & Junod published an article on mental health in old age in the WHO Chronicle. They gave an account of the WHO programme in this age group, which included information and training, tools, diagnostic criteria and methods for diagnosis, the management of mental disorders and psychosocial problems, and drug treatment in the elderly. It was now clear that the diagnosis of the dementias had become a crucial issue internationally, both for services and for research. A wellreceived contribution to the matter came with the book Classification and Diagnosis of Alzheimer’s Disease, edited by Hovaguimian et al (1989). Publications by Orley (1990) and Bertolote & Orley (1990) have described investigations aiming to produce data on the epidemiology of dementia, and assessment methods for people attending clinics or other services for the elderly. An especially noteworthy achievement is the successful completion of a methodological study on assessment methods. This focused on the difficult interface between dementia and depressive disorder, and involved all five university psychiatry departments in Switzerland. The work was initiated by the late Professor Kielholz in Basle, with the collaboration of Dr Sartorius (Kielholz et al, 1995). In recent years, two multi-site studies using the Geriatric Mental State Examination have been set up in collaboration with Professor John Copeland. The first study is on the incidence, prevalence, and risk factors of dementia. It involves centres in Brazil, Canada, India, Israel, South Korea, Nigeria, Singapore, Spain and the United Kingdom. The second is on the reliability and applicability of instruments for the diagnosis of dementia in different cultural settings, and involves centres in Bulgaria, Canada, Finland, India, Russia, Sweden and the UK.

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ICD–10 and the health of the elderly One of the Division’s major contributions towards a common language in mental health has been the preparation of ICD–10 and its ‘Section F0’ on cognitive disorders. For the dementias, as for all other categories, the Diagnostic Guidelines and the Diagnostic Criteria for Research (DCR) have been prepared after very thorough consultation with experts throughout the world, and are now being used and evaluated. It is clear that the ICD–10 criteria are going to have a major impact on the international research community, in the fields of both mental health and public health. Some publications are already appearing, and my colleagues and I in Australia are happy to number among their authors, with three papers reporting the use of ICD–10 in epidemiological studies (Henderson et al, 1993, 1994; Christensen et al, 1995). Mild cognitive disorder An initiative of particular interest has been the introduction to ICD– 10 of a new category, Mild Cognitive Disorder (F06.7). There are sound reasons to suspect that, throughout the world, there are large numbers of people of all ages who have suffered some insult to the brain at some point during their lives, and who thus have some degree of impaired cognitive performance in day-to-day life. This may be the consequence of malnutrition, parasitic infections, HIV infection, and possibly environmental pollution. Mild cognitive disorder may also occur in later life because of brain pathologies, including the accelerated changes of aging. Accordingly, it seemed appropriate to construct a new and explicitly experimental category to accommodate this important group of people. Mild cognitive disorder is characterised as follows: objective evidence of cerebral disease, a complaint of disorder in cognitive function made by the person or by a reliable informant, an abnormality in neuropsychological test performance, and the absence of dementia, delirium or another cognitive syndrome. Christensen et al (1995) applied these criteria to a community sample of elderly persons in Canberra. They found that the separate criteria correlated poorly and that cases of mild cognitive disorder did not differ substantially from the normal elderly in tests of cognitive function, but that the affected scored higher for anxiety, depression and neuroticism (possibly related to the complaint of cognitive difficulty). These are interesting findings which illustrate once more that the area of mild cognitive impairment, not amounting to dementia, is a problematic one. Further evidence is now needed to evaluate this


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new construct in ICD–10, not least because of its administrative and commercial significance in relation to the imminent availability of nootropic drugs to enhance cognition.

Disability and its measurement It is widely recognised that the Division of Mental Health has pioneered methods for assessing disability in persons with severe mental disorders, particularly the psychoses. Many of us are eagerly awaiting the revision of the International Classification of Impairment, Disability and Handicap, and of the Disability Assessment Schedule (DAS) (WHO, 1988). This same work on disability has brought valuable dividends for research on dementia and depressive disorders in the elderly, and on quality of life. The Disability Assessment Schedule has recently been adopted in epidemiological and clinical studies in this age group. Kay (1991) has argued that disability is a central issue in the diagnosis of dementia, possibly more important than neuropsychological test performance. There is no doubt that disability in the elderly, whether from physical disease, a cognitive disorder or a depressive state, is a matter of major importance to the sufferers themselves, to their families, and to health and social services. I am heartened that the Division of Mental Health has recognised this and included the issue in its programme. In addition to its work on morbidity in the elderly, the Division has undertaken work on well-being in this age group, with Willenbaum’s publication (1984) of a review of methods for its assessment. Continued activity on this important topic is expected. The Division of Mental Health has always placed great value on the formal working relationship it has established with the main international non-governmental organisations (NGOs) active in this field, including the Alzheimer Disease International and the International Psychogeriatric Association.

The contribution of Norman Sartorius The very content of the Division’s Programme of Work makes it clear that Dr Sartorius has been its central figure for a quarter of a century. It is a great pleasure to acknowledge this, and in so doing I would like to draw attention to five particular attributes of Dr Sartorius’s accomplishment. First, if one considers the deeper structure and conceptual architecture of the Programme of Work, it becomes apparent that it is an

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integrated whole – rather than a pastiche of disparate activities, each in response to some obligation arising in a member country or in another division of WHO. This integration is evident in the themes that permeate the whole programme. Foremost amongst these is the contribution towards a common language, as in the work on the ICD–10. Another is the development of instruments for measuring symptoms, or disability, or other factors that are immediately relevant to mental health. A further integrating theme is a consistent concern for those with severe mental disorders and their presentation, treatment and outcome. The second attribute of Dr Sartorius’s contribution is one which might easily escape our attention if we did not stand back from the immediacies of the situation. This trait is that the Division of Mental Health has operated as a world-class centre of excellence in psychiatric research, producing work that is always scientifically sound. It has done this while, at the same time, functioning as a division within WHO. That accomplishment has my sincere admiration. It is not easy to carry out scientifically good work in that setting, whether at WHO’s Geneva headquarters or at its regional offices. Projects often involve many participants working in very different geographical and economic settings and with a great range of scientific experience and sophistication, and time constraints are usually much tighter than is the norm in a university context. But the programme conducted by Dr Sartorius is an exemplar of how work of fundamental significance for global public health can be accomplished under such complex conditions. A third attribute is that the work done over these 25 years has had a truly beneficial effect on others, in all continents and regions of the world. It has inspired people, it has placed fertile themes before many who might not have entered the area otherwise, and it has, time and again, brought together groups of people with a common interest, providing them with a framework and enhancing their productivity. Without Dr Sartorius’s leadership, such work would never have been accomplished. It is this facilitatory function that deserves our recognition and appreciation. A fourth attribute is that Dr Sartorius has achieved all of the above while maintaining his own intellectual and scientific acuity, despite the complexity of his working environment both in Geneva and on an international scale. I suspect that there are many who would have lost their edge in such an environment, by dint of having their energies channelled elsewhere. The fifth and last quality is the support and partnership that he has received unfailingly from Mme. Vera Sartorius. I know that he is deeply aware of this, and of the privilege he has enjoyed in having such a


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partnership. On countless occasions, Vera Sartorius has welcomed so many of us to their home with warm hospitality and joy. This is surely an occasion to convey to her our sincere appreciation for this, and for so much that she has contributed to the world’s mental health.

References BERTOLOTE , J. M. & O RLEY , J. (1990) Diagnosis and assessment in psychogeriatrics: WHO perspectives. C & M Fundación Ciencia y Medicina, 22, 9–16. CHRISTENSEN , H., H ENDERSON , A. S., J ORM , A. F. et al (1995) ICD–10 Mild Cognitive Disorder: epidemiological evidence on its validity. Psychological Medicine, 25, 105–120. HÄFNER , H., M OSCHEL , G. & S ARTORIUS , N. (1986) Mental Health in the Elderly. A Review of the Present State of Research. Berlin: Springer-Verlag. HENDERSON , A. S., J ORM , A. F., M ACKINNON , A. J., et al (1993) The prevalence of depressive disorders and the distribution of depressive symptoms in later life: a survey using Draft ICD– 10 and DSM–III–R. Psychological Medicine, 23, 719–729. ——, J ORM , A. F., M ACKINNON , A. J., et al (1994) A survey of dementia in the Canberra population: experience with ICD–10 and DSM–III–R criteria. Psychological Medicine, 24, 473–482. HOVAGUIMIAN, T. & JUNOD, J.-P. (1986) Mental health in old age. WHO Chronicle, 40, 141–148. ——, H ENDERSON , S., K HACHATURIAN , Z. S., et al (eds) (1989) Classification and Diagnosis of Alzheimer Disease. Bern: Hogrefe & Huber. JORM, A. F., KORTEN, A. E. & JACOMB, P. A. (1988) Projected increases in the number of dementia cases for 20 developed countries. Acta Psychiatrica Scandinavica, 78, 493–500. KAY , D. W. K. (1991) Impairment, disability and dementia. International Journal of Geriatric Psychiatry, 6, 827–831. KIELHOLZ , P., A DAMS , C., B ECH , P., et al (1995) Depression and cognitive impairment in the elderly: a multicentre study. European Psychiatry, 10, 61–74. ORLEY, J. (1990) A WHO multisite epidemiological study of dementias in a community sample. In Psychiatry: A World Perspective (eds C. N. Stefanis, C. R. Soldatos & A. D. Rabavilas). International Congress Series 900, Vol. 4, pp. 127–131. Amsterdam: Excerpta Medica. WHO (1959) Mental Health Problems of Aging and the Aged. Sixth Report of the Expert Committee on Mental Health. WHO Technical Report Series No. 17. Geneva: World Health Organization. —— (1972) Psychogeriatrics. Report of a WHO Scientific Group. WHO Technical Report Series No. 507. Geneva: World Health Organization. —— (1979) Psychogeriatric care in the community. Public Health in Europe, 10. Copenhagen: WHO Regional Office for Europe. —— (1986) Dementia in Later Life: Research and Action. Report of a WHO Scientific Group. Technical Report Series No. 730. Geneva: World Health Organization. —— (1988) Psychiatric Disability Assessment Schedule. (WHO/DAS). Geneva: World Health Organization. W ILLENBAUM , G. G. (1984) The Wellbeing of the Elderly. Approaches to Multidimensional Assessment. WHO Offset Publication No. 84. Geneva: World Health Organization.

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11 WHO programmes on prevention and control of drug and substance misuse MARIO ARGANDOÑA and MARCUS GRANT

Introduction As we approach the end of the century, the time is ripe for looking back and pondering the achievements of an era that came to an end when Norman Sartorius retired from WHO, in the hopes that past experience may help us face the challenges of the future. It is especially meaningful to consider the personal role of Dr Sartorius who, for more than a quarter of a century, acted as a kind of fulcrum for virtually every mental health issue of international significance – including, of course, the mental health aspects of psychoactive substance use. In the motley area of psychoactive substance use, the contribution of Dr Sartorius and his staff at the Division of Mental Health can be best summed up in a single phrase – the establishment of rationality in place of ideology. This was achieved in at least three distinct domains: compiling and updating knowledge and experience; testing innovative approaches; and bringing order to conceptual chaos. We shall address each of these in turn. Key staff members, working under the direction of Dr Sartorius, produced remarkably comprehensive reports which spanned basic epidemiology, cross-cultural perspectives and reviews of prevention, treatment and policy experience. Dr Awni Arif, in the field of internationally controlled substances, and Mrs Joy Moser, in alcoholrelated problems, produced standard works which remain of lasting importance long since the social and political circumstances 138

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surrounding their compilation have changed (Moser, 1980, 1985; Arif, 1987a,b; Arif & Westermeyer, 1988) . For psychotropic substances, especially new chemicals produced by the pharmaceutical industry, the meticulous groundwork laid by Dr Inayath Khan for his sequence of Expert Committees to review drugs of dependence helped to establish MNH’s reputation as the most authoritative source of balanced information (WHO, 1964a,b, 1967, 1970, 1974, 1978–1990). In the area of alcohol-related problems, the build-up to the 1983 World Health Assembly technical discussions and the reports emanating from those discussions represent a cornerstone of the World Health Organization’s efforts to reduce problems caused by or associated with alcohol misuse (WHO, 1980, 1982).

Alcohol problems as public health problems Health and social problems related to the consumption of alcohol became a serious public health worry in the 1970s. In the WHO European Region in 1950, only three countries had an annual per capita intake of more than 10 litres. By 1979, 18 countries had reached this level of consumption. It was also noticed that commercially-produced alcoholic beverages, especially beer and spirits, were increasing sharply in Africa, Latin America and the Western Pacific. The Division of Mental Health played a central role in coming up with considerations and strategies to deal with this problem. Until the mid-1970s WHO’s main goal, like that of national health programmes, had been the treatment of ‘alcoholics’. Definitions of ‘alcoholism’ were not consistent, however, so WHO began to work on establishing a fresh classification of the range of disabilities associated with the consumption of alcohol. The first result was the definition of an ‘alcohol dependence syndrome’ and the recognition of a wide range of disabilities related to alcohol consumption, which need not necessarily imply alcohol dependence. These disabilities could be physical, psychological or social (Edwards, 1977). In 1979, WHO concluded that because of this very wide range of problems, public health efforts in the field must be expanded beyond the provision of treatment to individual problem drinkers. New strategies to prevent these problems included controls on the availability of alcohol, as well as educational programmes to advise people how to avoid patterns of drinking that might lead to problems with their health or well-being (WHO, 1980).

140 Argandoña & Grant One of the more important elements in the new approach was the radical change in attitudes towards the control of alcohol. Until the 1960s, researchers and public-health policy makers assumed that there was little correlation between the total amount of alcohol produced and consumed and the incidence of problems related to alcohol. However, the practical finding that alcohol problems were rising with the increased availability of alcohol suggested that programmes to restrict consumption of alcohol should be re-evaluated. A WHO study in the early 1970s concluded unequivocally that ‘changes in the overall consumption of alcoholic beverages have a bearing on the health of the people in any society. Alcohol control measures can be used to limit consumption’. While limiting alcohol may have beneficial effects on public health, however, it was recognised that there was a need to balance this with economic or fiscal interests. WHO publications highlighted the need for countries to develop and implement policies and programmes which are consistent not only with national health planners but also with overall economic and social development (Edwards & Arif, 1980). A body like WHO is uniquely placed to undertake major crossnational multi-centre research studies, and the Division of Mental Health, under the leadership of Dr Sartorius, exploited that potential to the full. In the field of alcohol use, two long-term projects deserve special note. The ‘community response’ project supported by the US NIAAA, involving collaborators in Mexico, Zambia, and Scotland, established a new way of tracking the extent and intensity of alcohol-related problems and the different ways in which contrasting cultures cope with, prevent, and treat them (WHO, 1984; Ritson, 1985). Likewise, the ‘brief interventions’ project involved six countries in the development of a simple screening instrument (AUDIT – the Alcohol Use Disorders Identification Test) and 10 in a comparison of different levels of brief interventions to address problematic drinking behaviour. It is an indication of the global and lasting relevance of both projects that they have been taken up and modified for use in many parts of the world other than those in which they were first tested (Babor, 1989). In order to assess the response of communities to alcohol-related problems, WHO undertook a detailed comparative study involving rural and urban populations in Mexico, Scotland and Zambia between 1976 and 1983 (Ritson, 1985). The study found important differences between the cultures in the place of alcohol in everyday life. But in all three countries, alcohol-related problems accounted for a substantial proportion of the caseloads in general community health and social services. While this Community Response Project did not come up with distinct and unique conclusions, it succeeded


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in shifting the focus on preventive and treatment strategies towards full community involvement. This shift has had profound implications for the way services are organised. In 1982 WHO began to develop a technology that could be used by primary health care workers to detect problems related to alcohol consumption at an early stage. The primary objective was to develop a simple screening procedure that would be crossculturally valid, useful for the purposes of intervention, and simple enough to be used by workers without a high level of training (WHO, 1986; Grant & Hodgson, 1991). The final product was the AUDIT (Babor, 1989), which was soon followed by a comparative study on brief interventions.

Problems related to other substances of abuse The developments in the field of alcohol consumption, discussed above, facilitated the work on psychoactive substances that, following the conventions of 1961 and 1971, have been known as ‘illicit drugs’ due to the establishment of international controls over their production, trade, possession and (in some countries) use. Although such substances are not similar to alcohol, it became clear that they shared the risks of producing the same range of health disorders, including the syndrome of dependence and a number of disabilities related to their consumption that did not necessarily imply dependence. In 1980 WHO published a list of the core data that should be collected in epidemiological studies to permit comparisons between one study and another. Investigators in nine countries examined the feasibility of obtaining information about key issues and agreed on a set of data that was relevant to drug control programmes and could be reliably obtained and used in international comparisons (Hughes, 1980). Later studies developed techniques for surveying drug use among students and other young people, and assessed reporting systems for substance misuse. At present WHO is preparing a Consolidated Epidemiological Manual for Substance Abuse, in order to help countries’ health information systems support their health policies and national health promotion activities (Rootman & Hughes, 1980; Smart, 1980, 1981) Another significant contribution was that, with the encouragement of the WHO Mental Health Division, many countries had come to see substance misuse as a problem for the health services. Before that, reaction to the problem ranged from official tolerance to the treatment of ‘addicts’ as criminals or psychotics. Since the

142 Argandoña & Grant 1980s, WHO has been supporting programmes in different regions of the world on the health aspects of illicit drug misuse, in collaboration with national authorities and other UN agencies; these projects have resulted in an improved delivery of services and have shed light on the aetiology and nature of the problem (WHO, 1981). WHO has placed particular emphasis on incorporating techniques for the prevention and treatment of drug misuse into primary health care. One study looked at the role of primary health care in the control of illicit drug and alcohol use and dependence. WHO has produced guidelines for training health workers in this field, which have been tried in several developing and developed countries (WHO, 1986, 1990a). Studies in individual countries have demonstrated the benefits of enlisting existing community services in the management of the problems related to psychoactive substance use. WHO has emphasised the need to be aware of the sociocultural context in which problems due to or associated with psychoactive substances occur, when designing programmes for prevention and treatment. A programme that works in one culture may be completely ineffective in another. The coordination of a wide range of national programmes has given WHO the opportunity to consider cross-national aspects of policies and programmes on the prevention and treatment of substance misuse (Edwards & Arif, 1980). In supporting national efforts in the treatment of drug- and alcohol-dependent persons, WHO realised that the success of such efforts depended partly on the introduction of appropriate legislation. Consequently, it has published a number of comparative surveys of legislation on drug and alcohol issues. The first survey of legislation on the treatment of substance-dependent persons was published in 1962. A 33-country review of problems and programmes in the field was published in 1974, including a brief survey of the use of legislation for control purposes. In 1978, WHO produced a major study of mental health codes in 43 countries, together with recommendations for improving and updating national legislation. This study dealt with treatment programmes for drug and alcohol dependence mainly as they related to overall national legislation on mental health care. Using this study as a model, WHO carried out a survey of legislation on the treatment of drug- and alcohol-dependent persons, again in 43 countries, which was published in 1986 (Porter et al, 1986). One of the recommendations resulting from this latest survey was that legislative guidelines should be developed that could be used by WHO Member States in the drafting of new legislation. This led directly to the 1987 publication of the ‘Guidelines for assessing and revising national


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legislation on treatment of drug- and alcohol-dependent persons’ (Curran, 1987). A new study called ‘Drug and alcohol dependence policies, legislation and programmes for treatment and rehabilitation’ has been prepared in an effort to update and expand former publications on the subject. The most important role assigned to WHO under the 1961 and 1971 UN treaties is to recommend narcotic drugs and psychotropic substances for international control. Since 1976, when the 1971 Convention on Psychotropic Substances came into force, WHO has been reviewing data on the risk/benefit ratio of a large number of groups of drugs and individual drugs, at the request of Member States and the UN Commission on Narcotic Drugs, as well as on its own initiative using information available to WHO from various sources. WHO has developed a methodology for the evaluation of psychotropic substances, which assesses both the problems they create and their usefulness (Rexed, 1984; WHO, 1990a). Several reviews and WHO Expert Committees on Drug Dependence have been held to make recommendations in this regard. In 1984, WHO’s recommendations regarding the control of commercially available benzodiazepines were debated by the UN Commission on Narcotic Drugs, which decided to place 33 of them on Schedule 4 of the 1971 Convention; in 1985, a list of 28 amphetamine-like substances was reviewed and WHO recommended that 17 of these be placed under control. WHO has recorded and evaluated more than 800 exempt preparations and will carry out further research on this subject, in order to highlight the principles involved and give guidance to national authorities. Based on WHO’s recommendations, the number of controlled narcotics has increased more than fivefold to 116, and the number of controlled psychotropics has tripled to 105. The responsibility to review substances is ongoing, and should continue as long as the present international drug control system is in place (Rexed, 1984). A number of methods for assessing the public health and social problems associated with the use of psychotropic drugs were reviewed in WHO publications that provided the methodologies for carrying out several studies in developing countries, and also suggested how to make psychotropic drugs safer. WHO has continued to develop new procedures for reviewing psychotropic substances, which have involved it with organisations and institutions in a position to contribute data, such as the International Federation of Pharmaceutical Manufacturers Associations, and pharmaceutical companies that produce psychotropic substances. One of the ways to make drug therapy more rational is for WHO to make scheduling recommendations for dependence-producing

144 Argandoña & Grant substances; another way is through cooperation among the medical and health-related professions, government authorities, pharmaceutical industries, and professional organisations. Several publications and other initiatives have been issued and developed in order to help medical schools, general practitioners and pharmacists approach the subject of the rational prescription of psychotropic substances (Idanpaan-Heikkilal, 1987; Ghodse & Khan, 1988).

International collaboration in the substance misuse field In hindsight, it could be asserted that it was in bringing order to conceptual chaos that Dr Sartorius and his team at the Division of Mental Health made their greatest international contribution. Within the context of the WHO/ADAMHA collaborative project, special attention was devoted to mental and behavioural disorders caused by the use of psychoactive substances. As a result, diagnostic criteria were developed with a sensitivity to different cultures and diagnostic traditions; clinical and epidemiological instruments were produced and tested; lexicons of terms were compiled and given shape; and the political whims and fashions of particular administrations were placed in sharp contrast with the results of scientific enquiry and steadfast empiricism. The several versions of Chapter V (Mental and Behavioural Disorders) of the International Statistical Classification of Diseases and Related Heath Problems, Tenth Revision (ICD–10), especially the ‘Clinical Description and Diagnostic Guidelines’ and the ‘Diagnostic Criteria for Research’, are landmarks in the history of the classification, and clarification, of disorders caused by the use of psychoactive substances (WHO, 1992, 1993) The WHO/NIH Joint Project on diagnosis and classification culminated in the cross-cultural applicability research (CAR) of criteria for the diagnosis of substance use disorders and of instruments used for their assessment. Nine centres from different cultures, representing different languages and different patterns of use of alchol and other psychoactive substances, were selected in the following locations: Ankara, Turkey; Athens, Greece; Bangalore, India; Flagstaff, Arizona, USA (Navaho culture); Ibadan, Nigeria; Jebel, Rumania; Mexico City, Mexico; Santander, Spain; and Seoul, South Korea. This array of disparate cultures was compared to a nine-floor Tower of Babel, where people of varied ethnic origins and religions were speaking a different language (and even different dialects of a


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given language) on every floor, and using psychoactive substances in many different ways (Room et al, 1996). The CAR studied the applicability of CIDI (the Composite International Diagnostic Interview) and SCAN (Schedules for Clinical Assessment in Neuropsychiatry), which are members of the family of assessment instruments developed under the WHO/NIH Joint Project (WHO 1990b; WHO 1994). The study was a multidisciplinary effort by psychiatrists, anthropologists, sociologists, epidemiologists, psychologists and linguists who designed a range of methodologies for data collection and the validation of findings from various sub-studies. In the end, the CAR built a common cross-cultural framework of concepts, as well as a network of centres and experts who are able to communicate and agree despite their different cultural backgrounds and the different social mores influencing the diagnosis and assessment of psychoactive substance use disorders. This has provided fertile ground for future comparative and collaborative research on such disorders. Without relaxing the focus on the intellectual quest for clarity and comprehension, and against the absurdity of moralistic prescriptions for utopia and the intolerance of disproportionate penalisation, Dr Sartorius always fortified the public health approach to and the medical management of health disorders caused by the use of psychoactive substances. He justified this position with his conviction that the objectives of managing problems related to substance use do not differ from the overall WHO objective, i.e. the attainment by all peoples of the highest possible level of health. The area of psychoactive substance use is particularly at the mercy of political cross-currents, and it is to the credit of Dr Sartorius and his succession of collaborators that they were able not only to keep their heads above water, but also to strike out boldly for the shore of rationality and avoid being wrecked on the reefs of expediency. It did not always make for the most popular programme (there were disputes with some member states, and even with some regional offices), but in the end it earned considerable global respect. As already noted, over the years the Division of Mental Health prepared and coordinated a number of WHO Expert Committees on both mental health and drug dependence (WHO, 1970, 1974, 1978–1990) as well as scientific groups and study groups on specific topics (such as the use of cannabis, youth and drugs, or problems related to alcohol consumption). At these technical forums, international experts representing different trends and cultures had the chance to deliberate about prevention, treatment and rehabilitation. A review of their content has demonstrated that, in addition

146 Argandoña & Grant to drug control measures, the World Heath Organization established a range of consistent opinions on how to meet the needs of people harmed by psychoactive substances. The five core opinions are as follows: The adverse consequences of psychoactive substance use are regarded as health events, which can be studied with scientific methods and dealt with by medical approaches. When problems related to substance use increase within a given society, they are seen as epidemics that may be understood with epidemiological studies, and controlled or prevented with public health measures. The use of any psychoactive substance, independently of its legal status or social acceptability, can be potentially harmful; policies to reduce such harm must be comprehensive and respectful of cultural mores. The social environment and response, including policies, legislation, and community traditions, are crucial in the evolution and eventual outcome of substance use and related problems. Current knowledge about the factors influencing substance use initiation, ongoing use, associated problems and patterns of cessation are still incomplete in many areas, so interventions and decisions to tackle such problems have to be rigorously evaluated. Despite these opinions, there is still vivid debate around topics like the following: (i) whether the dependence syndrome is a disease to be treated or a sinful behaviour to be eliminated; (ii) whether persons affected by disorders due to substance use are entitled to equal access to health and social services and to common human rights; (iii) whether interventions on the market for controlling the supply of and demand for drugs are as effective as education and health promotion; (iv) whether some licit dependence-producing substances should not be internationally controlled.

Conclusion Maybe it was because of these debates that WHO attempted to sever the ties linking the controversial area of psychoactive substances with the undisputed facts and principles of mental health. Although it can certainly be argued that substance misuse is both more and less than mental health, it is equally true that substance misuse needs a home in WHO, if only to protect it from politics and fashion. As an independent programme, the Substance Abuse Department (SAB) was able to


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increase the demand for health responses in those hidden groups in which substances were causing the greatest harm, such as homeless adults, street children, indigenous peoples, and injection drug users, and where overlooked substances – like volatile solvents – have devastating effects on the health of deprived populations. Lastly, whether or not to include tobacco issues in SAB requires some thought: it has been recognised not only that tobacco is the top killer among psychoactive substances and the most liable to produce serious dependence syndrome, but also that there is a close association between smoking and alcohol consumption and between smoking and illicit drug use. The implication of such associations is that the profile of the cigarette smoker is becoming more like the profile of those who use illicit drugs and drink heavily. For many years smoking was regarded as a relatively benign social habit, but it seems that its innocence has now been firmly belied. The new Mental Health Department (MNH) will have to take special care with issues of equity, as emphasised by the former Secretary General of the United Nations, Boutros Boutros-Ghali, when he introduced the report titled World Mental Health: Problems and Priorities in Low Income Countries. He stated that the report drew attention to the adverse effects of violence, suicide, alcoholism and drug misuse, and that these problems destroy lives and subvert societies as much as any external aggressor. He stressed that priorities must change and that mental health must be recognised as a foremost target. We hope that the legacy of Dr Sartorius will help people working in the field of psychoactive substance use to face such an expanded, and perhaps intimidating, concept of mental health area. There is a children’s book called Where The Wild Things Are. The land of the wild things is rather like the field of substance misuse, full of grotesque creatures who ‘roar their terrible roars, and roll their terrible eyes, and show their terrible claws’ until one day somebody comes along who tames them ‘by the magic trick of staring into all their yellow eyes without blinking once’. That was the magic trick of Norman Sartorius. He kept the wild things in order and we love him for it.

References ARIF, A. (ed.) (1987a) Drug Dependence: A Methodology for Evaluating Treatment and Rehabilitation. WHO Offset Publication No. 98. Geneva: World Health Organization. —— (ed.) (1987b) Adverse Health Consequences of Cocaine Abuse. Geneva: World Health Organization. ARIF , A. & W ESTERMEYER , J. (eds) (1988) Methadone Maintenance in the Management of Opioid Dependence: Programs and Policies Around the World. WHO/MNH/PAD/88.12. Geneva: World Health Organization.

148 Argandoña & Grant BABOR , T. F. (ed) (1989) AUDIT, The Alcohol use Disorders Identification Test: Guidelines for Use in Primary Health Care. WHO/MNH/DAT/89.4. Geneva: World Health Organization. CURRAN, W. J. (ed.) (1987) Guidelines for assessing and revising national legislation on treatment of drug- and alcohol-related persons. International Digest of Health Legislation, Vol. 38, Suppl. 1. Geneva: World Health Organization. EDWARDS , G. (ed.) (1977) Alcohol-related Disabilities. WHO Offset Publications No. 32. Geneva: World Health Organization. EDWARDS , G. & A RIF , A. (eds) (1980) Drug Problems in the Sociocultural Context: A Basis for Policies and Programme Planning. Public Health Papers 73. Geneva: World Health Organization GHODSE , H. & K HAN , I. (eds) (1988) Psychoactive Drugs: Improving Prescribing Practices. Geneva: World Health Organization. GRANT, M. & HODGSON, R. (eds) (1991) Responding to Drug and Alcohol Problems in the Community, A Manual for Primary Health Care Workers, with Guidelines for Trainers. Geneva: World Health Organization HUGHES , P. H. (ed.) (1980) Core Data for Epidemiological Studies on Nonmedical Drug Use. WHO Offset Publication No. 56. Geneva: World Health Organization. IDANPAAN -H EIKKILAL (ed.) (1987) Psychoactive drugs and health problems. Report of a meeting by WHO with the collaboration of the Government of Finland, the Government of Thailand and UNFDAC. Helsinki: Finnish National Board of Health. MOSER, J. (1980) Prevention of Alcohol-related Problems: An International Review of Preventive Measures, Policies, and Programmes. Toronto: ARF and World Health Organization. —— (ed.) (1985) Alcohol Policies in National Health and Development Planning. WHO Offset Publication No. 89. Geneva: World Health Organization. PORTER, L., ARIF, A. & CURRAN, W. (1986) The Law and the Treatment of Drug and Alcohol Dependent Persons. Geneva: World Health Organization. REXED , B. (ed.) (1984) Guidelines for the Control of Narcotic and Psychotropic Substances. Geneva: World Health Organization. RITSON , E. B. (1985) Community Response to Alcohol-related Problems. Review of an International Study. Public Health Papers 81. Geneva: World Health Organization. ROOM, R., JANCA, A., BENNETT, L. A., et al (eds) (1996) WHO cross-cultural applicability research on diagnosis and assessment of substance use disorders: an overview of methods and selected results. Addiction, 91, 199–220. ROOTMAN , I. & H UGHES, P. H. (1980) Drug-abuse Reporting Systems. WHO Offset Publication No. 55. Geneva: World Health Organization. SMART , R. G. (ed.) (1980) A Methodology for Student Drug-use Surveys. WHO Offset Publication No. 50. Geneva: World Health Organization. —— (ed.) (1981) Drug Use among Non-student Youth. WHO Offset Publication No. 60. Geneva: World Health Organization. WHO (1964a) Expert Committee on Addiction-Producing Drugs. Thirteenth Report. Technical Report Series 273. Geneva: World Health Organization. —— (1964b) Evaluation of Dependence-Producing Drugs. Report of a WHO Scientific Group. Technical Report Series 287. Geneva: World Health Organization. —— (1967) Services for the Prevention and Treatment of Dependence on Alcohol and other Drugs. Expert Committee on Mental Health, Fourteenth Report. Technical Report Series 363. Geneva: World Health Organization. —— (1970) WHO Expert Committee on Drug Dependence. Eighteenth Report. Technical Report Series 460. Geneva: World Health Organization. —— (1974) WHO Expert Committee on Drug Dependence. Twentieth Report. Technical Report Series 551. Geneva: World Health Organization. —— (1978–1990) Expert Committees on Drug Dependence, 21st to 26th Reports. Technical Report Series No. 618 (1978), 729 (1988), 741 (1985), 761 (1987), 775 (1989), and 787 (1990). Geneva: World Health Organization.


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—— (1980) Problems Related to Alcohol Consumption. Report of a WHO Expert Committee. Technical Report Series 650. Geneva: World Health Organization. —— (1981) Assessment of Public Health and Social Problems Associated with the Use of Psychotropic Drugs. Technical Report Series No. 656. Geneva: World Health Organization. —— (1982) Thirty-fifth World Health Assembly, Technical Discussions, Document A35/Technical Discussions/1, on Alcohol Consumption and Alcohol-related Problems: Development of National Policies and Programmes. Geneva: World Health Organization. —— (1984) Community Responses to Alcohol-Related Problems. Washington, DC: NIAAA and World Health Organization. —— (1986) Drug Dependence and Alcohol-related Problems. A Manual for Community Health Workers with Guidelines for Trainers. Geneva: World Health Organization. —— (1990a) Revised Guidelines for the WHO Review of Dependence-producing Psychoactive Substances for International Control. PND/90.1 Geneva: World Health Organization. —— (1990b) CIDI, Composite International Diagnostic Interview. Geneva: World Health Organization. —— (1992) The ICD–10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization. —— (1993) The ICD–10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva: World Health Organization. —— (1994) SCAN, Schedules for Clinical Assessment in Neuropsychiatry. Geneva: World Health Organization.

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Part IV. Regional and national mental health programmes

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12 Development of regional and national mental health programmes NARENDRA N. WIG

Introduction Of all of WHO’s activities, perhaps the most crucial is the development of health programmes at the country level. Efforts aimed at increasing scientific knowledge, transferring technology, and establishing networks of experts should help countries develop their own health programmes and set them on the road to achieving the cherished goal of health for all. In most countries, especially in the Third World, mental health has ranked very low among health programme priorities. One of WHO’s important contributions, in recent years, has been to persuade health planners in developing countries of the importance of mental health programmes and to encourage them to develop these in the framework of public health programmes. In this paper, I will review how this development has taken place over the last two decades, with a particular emphasis on countries in Asia and Africa – the region with which I am most familiar.

Emergence of mental health as an important public health issue While psychoanalysis had sensitised health professionals earlier in this century about the importance of psychological factors in health and disease, it was only after the Second World War that the real magnitude of mental health problems was fully acknowledged. Two 153

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seminal WHO publications, Epidemiological Methods in the Study of Mental Disorders, by Reid (1960), and The Scope of Epidemiology in Psychiatry, by Lin & Standley (1962), contributed significantly to this development. A number of field surveys conducted in developing countries in the 1950s and 1960s found high rates of mental disorders in the community, generally comparable to those found in industrialised countries (Lin, 1953; Giel & Van Luijk, 1969; Dube, 1970). Health planners in developing countries, however, remained sceptical about the relevance that mental health should be afforded within public health programmes. Among many severe health problems, including over-population, malnutrition, infectious diseases and poor sanitation, health planners found it difficult to give priority to mental health issues. In the 1970s the situation started to change slowly due to various factors, including the following: (1) The rapid increase in the number of psychiatrists and other mental health professionals in developing countries, due mainly to the establishment of local training centres. (2) The emergence of general hospital psychiatry backed by outpatient psychiatric services as a major alternative to traditional, isolated mental hospitals. (3) The rapid growth of psychopharmacology and the ease of obtaining effective psychotropic drugs for various mental disorders, which were clearly superior to the earlier traditional and folk methods of illness management. All these factors helped reduce the stigma against mental illness, thus boosting the demand for modern mental health services. However, most mental health facilities remained in the big cities, so coverage was provided largely to the more affluent segments of the population. During the last 20 years, the World Health Organization has played a crucial role in advocating mental health care as an important part of public health programmes in developing countries. To this end, it has undertaken a series of coordinated activities backed by inspiring leadership at its headquarters and regional offices and at the country level. The biggest battle has been to keep the definition of mental health broad and not to let WHO’s mental health programmes be confused with or identified only as programmes for clinical psychiatry, or for the treatment and rehabilitation of mental disorders. From the very beginning, emphasis was placed on the wide scope of mental health programmes, which were to include not only activities for the promotion of mental health and the prevention and treatment of neurological and mental disorders, but also efforts to improve the functioning of general health services, to foster overall socio-economic development, and to enhance quality of life.


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The issue of ‘Psychosocial factors and health’ was first raised during the Technical Discussions of the Twenty-Seventh World Health Assembly in 1974. The proposals for a programme on this theme were accepted by the World Health Assembly in 1976 (Resolution WHA 29.21). One of the recommendations made by the Second Coordinating Group for the WHO Mental Health Programme, which met in Manila in August 1977, reads as follows (WHO, 1977): In the opinion of the Group, the main reason for the increased acceptance and support of mental health programmes by decision makers and public health administrators is the new image of mental health that has emerged in the past few years. This image stresses the public health and social aspects of mental health, rather than linking it only to mental diseases and to psychiatry as a specialised branch of medicine. Responsibility for mental health should lie with the whole health team, other social services and with the community at large. This process of de-specialisation, integration and extension of care opens a completely new range of mental health work. Multidisciplinary involvement is obviously a prerequisite for such an approach to succeed.

The impact of the primary health care approach on mental health programmes A major development in the field of health was the emergence of the concept of primary health care, in the 1970s. The old style of health service delivery, by means of centralised institutions located in large cities and run by highly trained medical professionals, was generally found to be inadequate and inappropriate for the needs of large rural populations in developing countries. Equity in health and the involvement of the community were seen as the crucial elements in this new global movement of health. Mental health, like other branches of care, was affected by this new philosophy. The World Health Organization played a key role in bringing mental health into the immediate scope of primary health care, and in advocating delivery of mental health services through the network of primary health care services. Although it may now seem commonplace, in the 1970s, the integration of mental health into general health services and the training of primary health workers in mental health were considered revolutionary ideas. It is to WHO’s credit that these ideas were shown to be practical, so that they could be gradually incorporated into the mental health programmes emerging at the national level.

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In December 1973 WHO sponsored an inter-regional seminar called ‘Organisation of mental health services’ in Addis Ababa, which was attended by many influential mental health professionals from developing countries. The true breakthrough, however, came with the powerful 16th report of the Expert Committee on Mental Health, entitled ‘Organisation of mental health services in developing countries’. With the possible exception of the ICD publications, perhaps no other WHO document has had such a profound influence on the development of mental health services in developing countries. In 1976, soon after its publication, the Division of Mental Health in Geneva launched an international collaborative study called ‘Strategies for the extension of mental health services in the community’. The study involved seven countries (Brazil, Colombia, Egypt, India, the Philippines, Senegal and Sudan) and its results were published in Technical Report Series 698, Mental Health Care in Developing Countries (WHO, 1984). Later replicated in many other countries, the study clearly established the feasibility of incorporating mental health services into primary health care by selecting priority conditions to be managed by primary care doctors and other adequately trained health personnel, and by providing essential neuropsychiatric drugs and referral facilities. It had a powerful impact on the planning of mental health services in many developing countries. By demonstrating the feasibility of such a programme, it helped immensely in the later development of national mental health programmes in countries such as Tanzania, India, and Pakistan. An even more crucial milestone was the Alma Ata Declaration of 1978, in which ‘promotion of mental health’ was accepted as an essential element of primary health care. The third meeting of the Global Coordinating Group on Mental Health, held in Alexandria, Egypt in September 1979, perhaps set the agenda for the future development of national mental health programmes with the following observation (WHO, 1979): As an aftermath of Alma Ata, many countries have moved rapidly towards comprehensive national primary health care programmes, regarded as the priority for future health action. Recommendation 5 of the Alma Ata conference clearly establishes the ‘promotion of mental health’ as an essential element of primary health care. There is therefore an urgent need to establish mechanisms at the national level to ensure a full consideration of mental health within national primary health care programmes. Areas to be included are the prevention and care of mental disorders within primary health care, the psychosocial component of primary health care (for example, the promotion of health behaviour) and the promotion of positive mental health. Where national coordinating groups exist, they can


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provide the necessary input to the planning and programming of national primary health care activities. The WHO mental health programme should also take steps to ensure that results of current activities relevant to primary health care, for example, field projects on mental health care at community level, selection of drugs and supplies, training of health workers and inter-sectoral collaboration, are made available to national authorities.

In the 1980s, a number of countries in different parts of the world started developing national programmes of mental health, generally with WHO’s guidance and support. A comprehensive review of the principles of primary mental health care is contained in the publication The Introduction of a Mental Health Component into PHC (WHO, 1990).

Emergence and features of national mental health programmes It is difficult to say which was the first country to start a national mental health programme as such, because a number of activities related to the development of national programmes took place almost simultaneously in a number of countries. In WHO documents, the term ‘national mental health programme’ first appeared in the report of the 4th Global Coordinating Group meeting, held in New Delhi in October 1981. It is mentioned as the ‘new’ proposed activity for the South-East Asia Regional Office for the biennium 1982–83 (WHO, 1981). In 1977, the Thirtieth World Health Assembly adopted a resolution (WHA 30.45) for a ‘special programme of technical cooperation in mental health’. This resolution urged the member states to develop plans for mental health actions within the general health and other social services. Following this resolution, a number of countries in southern Africa formed the African Mental Health Action Group, with the aim of ‘planning and coordinating mental health programmes of the countries’. The plan of action, adopted in 1978, lists a number of activities related to the development of a national mental health policy, the training of existing staff and the delivery of service. The first ‘broad based, long-term national mental health programme’ (as opposed to just a project) was set up in Tanzania, starting in 1979, with the support of WHO and DANIDA (see Schulsinger & Jablensky, 1991). Around the same time, in 1981, the Ministry of Health of India asked this author to convene an expert group in order to formulate a national mental health programme for that large and densely populated

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country. In July 1981, after intensive discussions, the programme was presented at a workshop in New Delhi attended by more than 70 leading mental health experts drawn from every state in India, and in the following year it was presented at the country’s highest health forum, the Central Council of Health and Family Welfare. In 1984 it was made a part of the 7th national Five-Year Plan, which began in 1985. During the 1980s, many countries in different WHO Regions started developing and implementing national mental health programmes. The main features of these national programmes, as they emerged over the years, were as follows: Comprehensiveness. The programmes were always broad in scope and in nature, and always included five essential components: (a) promotion of mental health; (b) prevention of mental and neurological disorders; (c) treatment and rehabilitation of the mentally ill; (d) improvement of the functioning of general health services; and (e) adoption of strategies aimed to foster the overall socio-economic development and the improvement of the quality of life of individuals. Multi-sectoral nature. If adequate coverage were to be given to the various elements of the programmes, as listed above, it was obvious that mental health professionals alone could not carry out all programme activities. For example, the substance misuse programmes had to be tied in with the ministries of law and justice and with the police; the programmes for the promotion of mental health required close collaboration with the ministry of information, the press and the media as well as with many non-governmental organisations and religious groups. Likewise, programmes on mental retardation and school mental health had to be planned together with the ministry of education, while the ministry of social welfare had to be involved in the rehabilitation of the mentally ill. In some countries such collaboration was promoted by forming multisectoral national coordination groups, whereas in others it was limited to particular programme areas, like school mental health programmes or the organisation of primary health care services. Linkage with primary health care. After the Alma Ata declaration in 1978, primary health care was adopted as the key element of all WHO programmes. Since there is a great shortage of mental health professionals in most developing countries, mental health care was expected to be delivered through the existing network of primary health care services, especially for populations living in large rural areas. This programme required extensive training of existing primary care physicians, health


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assistants, health workers, nurses, etc. Collaboration with health administrators responsible for primary health care programmes was of crucial importance. Equally important in this programme was the provision of essential neuropsychiatric drugs and referral arrangements for more difficult cases. Involvement of the community. Active community involvement was considered crucial for the success of the mental health programmes. In many places, village mental health committees were formed in which village heads, religious leaders, teachers, and health care workers all participated. In some countries (such as Pakistan and Iran), school mental health programmes evoked an overwhelming response from the community, with students, teachers, parents, and village leaders all joining hands for the sake of further progress. These characteristics have continued to define new mental health programmes in an increasing number of developing countries, and form the backbone of WHO’s current activities in many parts of the world.

A tribute to a leader I would like to close this chapter with a personal tribute to a great leader, Norman Sartorius. Although it is true that a large number of people in many lands contributed to the success of national mental health programmes, the achievement was born from the vision of one man who dared to dream of a new future for mental health. We were all fortunate to be a part of this magnificent effort to win mental health its rightful position in health programmes the world over. Some leaders are good at counting trees but miss the forest, while others can see the forest but have no patience to count the individual trees. In Norman Sartorius we had a unique leader who could not only inspire us with his great vision, but who also had an infinite capacity to go into the most minute details of the programme in order to ensure its success. He was physically present with us in every country whenever a significant development in the mental health programme took place. No other person in recent times has done more for the advancement of mental health in developing countries. Almost every leading national mental health figure in every developing country has a warm, personal relationship with Norman Sartorius and can turn to him in times of need. He has helped earn mental health a position of priority within public health programmes. The emergence of national mental health programmes in many countries, in all corners of the world, is a lasting tribute to his name.

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References DUBE, K. C. (1970) A study of prevalence and biosocial variables in mental illness in a rural and an urban community in Uttar Pradesh, India. Acta Psychiatrica Scandinavica, 46, 327–359. GIEL , R. & V AN L UIJK , J. N. (1969) Psychiatric morbidity in a small Ethiopian town. British Journal of Psychiatry, 115, 149–162. L IN , T. Y. (1953) A study of the incidence of mental disorders in Chinese and other cultures. Psychiatry, 16, 313–336. —— & Standley, C. C. (1962) The Scope of Epidemiology in Psychiatry. Public Health Paper No. 16. Geneva: World Health Organization. REID , D. D. (1960) Epidemiological Methods in the Study of Mental Disorders. Public Health Paper No. 2. Geneva: World Health Organization. SCHULSINGER , F. & J ABLENSKY , A. (eds) (1991) The National Mental Health Programme in the United Republic of Tanzania: A Report from WHO and Danida. Acta Psychiatrica Scandinavica, 83 (Suppl. 364). WHO (1977) Report of the Second Meeting of the Coordinating Group for the WHO Mental Health Programme, Manila, 18–24 August 1977. WHO/MNH/77.4. Geneva: World Health Organization. —— (1979) Report of the Third Meeting of the Coordinating Group for the WHO Mental Health Programme. Alexandria, 10–14 September 1979. WHO/MNH/79.38. Geneva: World Health Organization. —— (1981) Report of the Fourth Meeting of the Coordinating Group for the WHO Mental Health Programme. New Delhi, 22–28 October 1981. WHO/MNH/82.4. Geneva: World Health Organization. —— (1984) Mental Health Care in Developing Countries: A Critical Appraisal of Research Findings. Report of a WHO Study Group. Technical Report Series 698.1. Geneva: World Health Organization. —— (1990) The Introduction of a Mental Health Component into PHC. Geneva: World Health Organization.

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13 The AMRO/WHO initiative to restructure psychiatric care in Latin America* ITZHAK LEVAV and BENEDETTO SARACENO

Introduction Over 200 participants from 11 Latin American countries met in Caracas, Venezuela, in November 1990 to review the status of psychiatric care in the region. As a result of this review, the conference adopted policy guidelines that crystallised into what later became known as the Caracas Declaration (González & Levav, 1991). The principles postulated in the Declaration refer to the need for developing psychiatric care in close connection with primary care and within the framework of the local health systems (Paganini & Capote Mir, 1990). This strategy has a double implication: the mental hospital ceases to be the single most important component of psychiatric care, while community-based services are established as the chief means to attain accessible, decentralised, comprehensive, continuous and preventive care. It also advocates the need to update the pertinent legislation in order to anchor the restructuring of the services in a legal framework and to assure proper safeguards for the human and civil rights of patients. The conference was convened by both the American Regional Office and the headquarters of the World Health Organization, with the co*This chapter is based in part on the article: L EVAV , I., R ESTREPO , H. & G UERRA DE MACEDO , C. (1994) The restructuring of psychiatric care in Latin America: a new policy for mental health services. Journal of Public Health Policy, 15, 71–85. We are grateful for the editor’s permission to use the paper for this book.

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sponsorship of a number of international, regional and national institutions from the mental health field and related areas. It was also attended by several American, Canadian, and European institutions (the latter from Italy, Spain and Sweden). This conference was rather different from others that had taken place in the region with similar aims. One distinct feature was the wide constituency it represented – professionals, political appointees (ministers and vice-ministers of health), legislators (senators and representatives), jurists, and a token group of consumers (a movement that has grown since the conference). Such heterogeneity expressed the organisers’ acknowledgement that mental healthrelated policies and programmes demand the engagement of a wide spectrum of social actors. Furthermore, by adopting the declaration mentioned earlier, and by endorsing the body of recommendations drafted by the working groups (González & Levav, 1991), the conference offered participating countries the main guidelines for a new common policy with regard to psychiatric care. The Caracas Declaration has had manifold repercussions in several quarters, including the media. A good deal of concrete action taken by the participating countries, as well as by several others that have joined since the initiative was launched, has shown that the movement it generated may succeed in promoting the needed reforms. This chapter will analyse the epidemiological and programmatic bases for action as well as the political, historical and technical background for this movement, known in the region as ‘The Initiative for Restructuring of Psychiatric Care in Latin America’. It will also analyse the broad implications of its health policy, the modus operandi of its implementation and monitoring, and the chief obstacles that it has encountered. Lastly, it will sketch the results achieved thus far.

The epidemiological basis for action Latin America, like the rest of the world (Kramer, 1980), is facing a pandemic of psychiatric disorders that discredits the notion that less developed societies are somehow immune to them. Indeed, community psychiatric surveys conducted in several countries in the region have shown that the magnitude of psychiatric disorders does not differ from that found in developed countries (Levav et al, 1989). Furthermore, violent behaviour – which gives rise to a range of problems of a psychosocial nature – is of outstanding magnitude and severity in this region, yet it is seldom recorded in psychiatric surveys. It should be noted here that the years of life lost as a result of violent behaviour


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among males in several countries in the region exceed those lost because of intestinal infections and cancer, two public health problems that have generated active programmes of intervention. The statistics chosen to represent violent behaviour in authoritative sources (Pan American Health Organization, 1990) are based on mortality, which fails to address the other, more frequent results of such behaviour, such as battered women and abused children. These behaviours do not always lead to death, yet they cause untold suffering and disability and a heavy burden on the health services. Violent behaviour is multi-determined; admittedly, mental health professionals may contribute only in part to its prevention. Their role in easing the psychological aftermath, however, is less questionable. Indeed, it is almost irreplaceable (Levav, 1991). Despite such a need, the contribution of mental health professionals remains limited. It is likely that their potentially helpful actions have been hampered by the operation of mental health services based on outmoded prescriptions and patterns of care which usually do not allow for treatment of the manifold expressions of violent behaviour. Today’s epidemiological picture seems of even greater concern if we project current prevalence rates to the year 2000, taking account of the demographic changes that will take place in Latin America. These changes will result from a double set of circumstances: the sheer increase in the population, and the modifications of the age distribution. As a result, the percentage increase of psychiatric disorders in Latin America and the Caribbean is expected to be higher than the percentage increase of the general population. It has been estimated that about 88 million people will show some emotional disorder by the beginning of the new century (Levav et al, 1989). And that estimate may be considered conservative, since the psychiatric impact of adverse social and economic processes that often affect the region was not taken into account in the calculation. These processes include the continuation of the chaotic process of urbanisation with its concurrent phenomena, such as the disruption of individuals’ social networks and the possible creation of a residue of less able individuals in the rural areas where psychiatric services are generally absent, as well as the increasing joblessness of relatively large subgroups of the populations due to adjustment of the economies. The high prevalence rates of these disorders also need to be judged against the social background of the region. Psychiatric disorders, of course, generate disability. The impact of disability on the largely precarious economies of the countries in the region may widen the gap between the goals for human development and the possibility the countries have of attaining these goals. It should be kept in mind that families living in adverse economic conditions may see their coping

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capacities overtaxed by the presence of a member affected by a mental disorder, in the absence of immediately available services with which to share the burden. In view of this epidemiological diagnosis and its implications, the convenors of the Caracas Conference deemed that restructuring of the psychiatric services in the region is an essential policy if (Mental) Health for All is not to be regarded as an illusory target.

WHO’s mental health programme WHO member states have mandated that national mental health programmes should be concerned not only with the control and prevention of mental disorders, but also with the relationship between psychosocial factors and overall health. However, this broad agenda requires expertise and resources. Most national mental health programmes still devote the largest portion of their efforts to the control of psychiatric disorders. The components of the agenda devoted to the primary prevention of those disorders susceptible to intervention (WHO, 1988) have been neglected. Likewise, action meant to promote the health of the communities is rarely undertaken. There are several reasons for this, one being the uneven allotment of resources for service, research and training by level of prevention (primary, secondary and tertiary). Where indeed are these resources assigned? Most of the funding in the field is tied to services generally provided in psychiatric hospitals, to training seldom provided in community-based settings, and to research that rarely deals with issues and problems originating in community-based care. The mental health services face a serious conflict: on the one hand, the current and forecasted needs for care are exceedingly high, and on the other, the generally lean budgets available to the mental health services are almost entirely used up on psychiatric beds. All of these factors hamper the development of action that adequately serves all the needs of the population in terms of health promotion, prevention, curative services, and rehabilitation. Both the participants and organisers of the conference were keenly aware of these facts when they drafted the Caracas Declaration, with its evolving policy implications.

The historical–political context Zilboorg (1941) pointed out that there is an association between the socio-political or ideological climate prevailing in a society and its


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concern for mental health and the care provided to the mentally ill. An early example is that the French Revolution promoted the liberation of mental patients from their shackles, and a more recent one is the President Kennedy era, which inspired a community mental health movement in the USA linked by Kennedy’s successor, President Johnson, to the social agenda subsumed under the War on Poverty. In Latin America, the demise of dictatorships in a number of countries at the end of the last decade brought about a renaissance of mental health issues in a general and societal concern for human rights. The state of the human and civil rights of psychiatric patients was indeed the subject of prominent discussion during the conference. The Caracas Declaration includes a statement on the legal principles that ought to guide the development of policies and programmes for the care of the mentally ill.

The technical basis for action We have already mentioned that the psychiatric services provided in Latin America lean heavily towards in-patient facilities. A simple calculation shows that the supply of services based on in-patient care cannot possibly accommodate current and future demands. Furthermore, recent results from the US-based Epidemiologic Catchment Area studies show that specialised services provide just a fraction of the psychiatric care needed, partly because people fail to consult specialised personnel even in communities with a well-developed network of services (Kramer et al, 1982). The WHO Division of Mental Health, led by Dr Norman Sartorius, carried out applied research that showed the capacity of the general health system to solve mental health problems, particularly if they enjoy the support of specialised services (Climens & Arango, 1983). The advantages of making mental health care available through primary health care are so obvious by now that further discussion risks redundancy. Studies conducted in a number of places have demonstrated that there is a spectrum of mental health caregivers ranging from self and family care to highly specialised services. Observations have shown that the mental health care provided in a large number of places in the region has yet to be inserted within an articulated network that will enable continuity of care, a sine qua non feature of the health services that facilitates successful intervention. Unlike a service organisation built according to a pyramid, which enables a smoother flow between levels, the mental hospital is usually found outside of the network, and plagued in its relative isolation by conditions said to be typical of ‘total institutions’ (Goffman, 1961). As

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a result, the care provided may be substandard, patients’ rights may be trampled upon, and hospitalisation is feared by the population.

The regional programmatic basis for action The XXIII Pan American Sanitary Conference (1990), which is the highest regional authority, approved Resolution XIII – ‘Strategic Orientations and Program Priorities for the Pan American Health Organization during the Quadrennium 1991–1994’ (Pan American Health Organization, 1991) – in order to pursue the goals of health and social development within the democratic system (Guerra de Macedo, 1991). A selective reading of the cited document suggests new tasks and prescribes novel areas of intervention for mental health programmes in the region. But the successful implementation of the agreed strategies and programmes does require a mutual accommodation between the technical cooperation provided by the WHO Regional Office and the countries’ mental health policies and programme structure. By virtue of Resolution XIII, mental health programmes are called to play an important role in promoting social policies that enhance the quality of life, including the psychological life, of individuals in the family and in the overall social arena, and, most importantly, in buttressing the reciprocal interaction between health and human development. Mental health programmes are expected, among other things, to address special concerted efforts in assisting high-risk groups in the communities, whether or not they seek specialised care. Resolution XIII calls for ‘strengthening and developing local health systems’ in its search for a service model that will assure greater equity while being more effective, efficient and participatory. To point out the role that mental health programmes could find in this context is to stretch the limits of this chapter, but it must be mentioned that at least two chief tasks are tailor-made for them. First, behaviour-related disciplines could contribute to the better organisation and management of the local health systems, given the particular human based difficulties to be found in intraand intersectoral coordination that characterises the new model. Secondly, the mental health field has already accrued experience in the operation of a service model that shares many of the features of the local health system (e.g. the assumption of responsibility for the health of a community, the so-called ‘catchment area’, and coordination with other human services such as education, welfare, etc.). The experience gained by the mental health profession could be of great service to the field of general health.


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Resolution XIII also emphasises the importance of integrating women into health and social development. There are a number of issues that hinder the implementation of such a strategy (such as low self-esteem or victimisation), and, conversely, that facilitate it (mutual support); many of these have psychological components. The mental health profession should join in the attempts made by other social agents to enfranchise half of the population of the region, making its singular contribution both by lowering the barriers that hamper women’s successful integration and by raising their overall psychosocial capacities. Resolution XIII sets eight priorities for the development of health programmes: health and the environment, food and nutrition, lifestyles and risk factors, control and preventable diseases, maternal and child health, workers’ health, drug addiction, and AIDS. In all of these, to a greater or lesser extent, behaviour-related disciplines (largely represented in the health sector by the mental health programmes) could play a pivotal role. Meeting the many additional challenges posed to the mental health sector by Resolution XIII requires freeing up and redirecting its hidden resources. The Caracas Declaration, by positing the restructuring of current psychiatric services, facilitates such a process.

Implementation The Regional Office of WHO has initiated an active, multifaceted programme of technical cooperation with the mental health agencies of all Latin American countries, with the collaboration of a number of institutions both from the Americas and Europe. The programme entails direct technical assistance, aimed chiefly at modifying the conditions of care provided at mental hospitals and the establishment or strengthening of demonstration projects of community-based services; the provision of appropriate scientific and technical information; the promotion of research related to the initiative; the organisation of training seminars for mental health personnel to upgrade their knowledge of the theory and practice of communitybased care, and to provide them with the appropriate set of skills; the provision of technical advice aimed at updating mental health legislation; and the mobilisation of local, regional and international resources. The WHO Regional Office has also been supporting national encounters, that are being convened by the countries’ mental health authorities. At these meetings, the basic initiative and the recommendations of the Caracas Conference are being analysed in order to

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adapt them to the local situation. It has been obvious from the outset that each country should set the scope, depth, course and modus operandi of the initiative as dictated by its needs, its resources, the will of its political officers, the attitudes of the community, and the commitment of its professionals to adopting the necessary reforms. As the WHO Regional Office has discussed with the countries and their cadres of technical advisors, the overall implementation of the project requires concerted action on a number of fronts. One of these is the enlightenment and mobilisation of public opinion on mental health matters by means of social communication. It is obvious that innovative community-based programmes can be successfully implemented provided that they fit the community’s ‘assumptive world’ (Frank, 1961). Furthermore, the community must zealously watch that the rights of its patients are being safeguarded and that the quality of the psychiatric care provided is as high as scientific standards determine and local conditions allow. This community alliance with the initiative includes the establishment and empowerment of consumer organisations; the national mental health agencies have gradually become active in facilitating their emergence and operation. A second component of the implementation strategies entails the modification of the content and loci of the training and education of health professionals (Pan American Health Organization, 1993). It will be almost impossible to achieve the goals of this initiative unless the educational programmes expose to future mental health workers the whole range of patients and disorders and the varied community problems, needs and resources. Such an opportunity is seldom available in a mental hospital-based teaching programme, but, as proposed by the Caracas Declaration, it is feasible in general hospitals, clinics, and other community-based institutions. A third avenue of implementation consists of actions leading to the generation and distribution of relevant information. Community care needs scientific bases for its operation just as much as hospitalbased care does. If community-based interventions are to withstand the test of time, they have to be submitted to rigorous testing, with regard, for example, to the overall effectiveness and costs of this treatment policy. To date, there is a paucity of research and information in Latin America on alternatives to mental hospital care, and more needs to be done in this area in order to strengthen the rational grounds of the initiative. Also crucial for the successful implementation of the initiative is the need to recruit the intellectual attention and support of the scientific and professional societies involved. The need to work with legislators and jurists on all issues related to ethics, human and civil


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rights, and service organisation has already been mentioned. Committees must be set up at both the central and local levels in order to monitor the ethics of psychiatric care.

Evaluation The WHO Regional Office for the Americas is monitoring the initiative closely and checking that action is taken in the above-mentioned areas. This procedure also helps the mental health authorities set and follow the right direction. Several years after the Caracas Conference, we can report a number of achievements and obstacles to the implementation of the initiative (see Pan American Health Organization (1996) for a recent update of its status). All Latin American countries have joined the initiative. Some have organised national conferences to discuss it. Six national administrations have passed decrees adopting it as national policy. Five countries have passed new laws prescribing community mental health care, or are in the process of revising their legislation. The Latin American Psychiatric Association congress in September 1992 and the Central American Psychiatric Association congress in March–April 1993 included one-day sessions on the restructuring of psychiatric care. Most recent meetings of the national psychiatric societies have done the same. Mental health consultants have been periodically visiting the countries to provide technical assistance. Lastly, the media have devoted space to the initiative in no less than 12 countries. The principles raised by the Caracas Declaration have penetrated the discourse of mental health care permanently; they are referred to often by Latin American professionals and non-professionals alike. However, technical implementation is progressing more slowly than hoped. The barriers are formidable: professionals and administrators in charge of budget allocations resist the effort lest the initiative change time-worn ways of practising their own status of authority within the mental health structure. In general, ideological stances rather than scientific evidence take the lead in the opposition to community-based care. The fear of a homeless underserved population brought about by unplanned deinstitutionalisation plays into the set of negative attitudes. Admittedly, the initiative implies that professionals must learn new techniques of intervention, teach incoming cohorts of trainees in as-yet unfamiliar settings, and conduct research on a new host of subjects and problems. Lastly, there are obstacles stemming from deeply rooted societal beliefs. Until now the mentally ill have been hidden behind impenetrable walls, but the initiative requires communities to tolerate and provide compassionate

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care within their own ranks. Such major reforms demand time; changes so broad can, and do, awaken resistance and require adjustment.

Conclusion Latin American countries have analysed the current and future needs of mental health care. They have also considered the role that mental health professionals could play in the implementation of the newer health orientations and strategies in effect in the region. In response to both, they have adopted the Initiative for Restructuring of Psychiatric Care, to which WHO is providing technical assistance. So far, the results of its implementation allow for cautious optimism that the initiative, despite major obstacles, may indeed achieve the aims sought by the Caracas Declaration in the pursuit of better mental health for the populations of Latin America.

References CLIMENS, C. & ARANGO, M. V. (1983) Manual de Psiquiatría para Trabajadores de Atención Primaria. Washington, DC: Pan American Health Organization. FRANK, J. (1961) Persuasion and Healing. Baltimore: Johns Hopkins University Press. GOFFMAN , I. (1961) Asylums. New York: Doubleday. GONZÁLEZ , R. & L EVAV , I. (1991) Restructuración de la atención psiquiátrica. Bases conceptuales y guías para su implementación. HPA/MND 1.91. Washington, DC: Pan American Health Organization. GUERRA DE M ACEDO , C. (1991) Health, Democracy and Social Development. Presentation at the Mario Negri Institute, Milan, Italy, 31 December 1991. K RAMER , M. (1980) The rising pandemic of mental disorders and associated chronic diseases and disabilities. In Epidemiologic Research as Basis for the Organization of Extramural Psychiatry. Acta Psychiatrica Scandinavica, 62 (Suppl. 285). ——, S IMONSICK , E., L IMA , B., et al (1982) The epidemiologic basis for mental health care in primary health care. A case for action. In The Epidemiology of Mental Health in Primary Care (eds B. Cooper & R. Eastwood). London: Routledge. L EVAV , I. (1991) Salud Mental y Conductas Violentas. Acta Psiquiátrica y Psicológica de América Latina, 37, 15–24. ——, L IMA , B., S OMOZA -L ENNON , M., et al (1989) Salud Mental para Todos en América Latina y el Caribe. Bases Epidemiológicas para la Acción. Boletín de la Oficina Sanitaria Panamericana, 107, 196–219. PAGANINI , J. M. & C APOTE M IR , R. (1990) Los Sistemas Locales de Salud. Conceptos, Métodos y Experiencias. Scientific Publication No. 519. Washington, DC: Pan American Health Organization. P AN A MERICAN H EALTH O RGANIZATION (1990) Health Conditions in the Americas, Vols I and II. Scientific Publication No. 524. Washington, DC: Pan American Health Organization. —— (1991) Strategic Orientations and Program Priorities 1991–1994. Washington, DC: Pan American Health Organization.


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—— (1993) Informe del II Grupo de Consulta sobre Enseñanza de la Psiquiatría en los Programas de Residencia. Panamá, 1992. Washington, DC: Pan American Health Organization (mimeo). —— (1996) Evaluación de la Iniciativa para la Restructuración de la Atención Psiquiátrica en América Latina. Washington, DC: Pan American Health Organization. WHO (1988) Prevention of Mental, Neurological and Psychosocial Disorders. WHO/MNH/EVA/ 88.1. Geneva: World Health Organization. ZILBOORG , G. (1941) A History of Medical Psychology. New York: Norton.

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14 Documents produced by WHO on policies, guidelines and legislation for mental health and illness JOSÉ M. BERTOLOTE

These documents can be grouped into the categories of legislation, consensus statements, guidelines, training, and others.

Legislation In 1976 WHO undertook a comparative analysis of mental health legislation, in light of the importance of legislation in terms of support to services. The study resulted in the publication of The Law and Mental Health: Harmonizing Objectives (Curran & Harding, 1978), which had a major impact in many countries. As an update to that project, a new ‘International review of mental health law’ was launched in 1992 and concluded in 1995. In addition to mental health laws, this new study examined social support legislation in 45 countries. The final report is available in draft format and will be published in the near future. An indirect result of that review was the publication of a guiding document for the improvement (or creation) of mental health legislation, entitled Mental Health Care Law: Ten Basic Principles with Annotations Suggesting Selected Actions to Promote their Implementation (WHO, 1996a). This was also an off-shoot of the UN’s 1994 Resolution on the Protection of Persons with Mental Illness and the Improvement of Mental Health Care. Another WHO contribution to the dissemination and implementation of the UN Resolution took the form of a document containing guidelines for the promotion of human rights of persons with mental disorders (WHO, 1995). 172

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Consensus statements This is an activity with a great power to standardise concepts and language, thus helping to establish a common understanding on basic issues related to mental health care. Two consensus statements have been produced as of late: one on psychosocial rehabilitation (WHO, 1996b) and the other on psychogeriatrics (WHO, 1996c). The production of these statements has always involved the participation of all relevant non-governmental organisations in their respective areas, and the opinions of internationally recognised experts.

Guidelines The Division of Mental Health (MNH) has issued several documents containing guidelines for the improvement of mental health services, starting with Baker et al’s pioneering paper on architectural guidelines for mental health services (1959). Other major topics covered by MNH guidelines are as follows: (a) organisation of mental health services in developing countries (WHO, 1975) (b) quality assurance in mental health care (WHO, 1990a) (c) essential treatments in psychiatry (WHO, 1993a,b) (d) primary prevention of mental, neurological and psychosocial disorders (WHO, 1998). This effort followed a report by the Director-General to the 39th World Health Assembly, which resulted in the adoption of a resolution on this particular topic (WHO, 1988a).

Training Training of the personnel delivering mental health care is fundamental to both the effectiveness and the quality of the care provided. The WHO Mental Health Programme contributes to this effort through the production of learning materials and through fellowships. Learning materials MNH has produced original materials, such as flow-charts for the management of frequent mental and neurological disorders (Essex & Gosling, 1982, 1983), and has also published an annotated biblio-

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graphy of training manuals addressed to primary health care workers (WHO, 1990b). Fellowships A catalogue issued in 1990 (WHO, 1990c) details the several types of fellowships offered in the field of mental health. Upon returning to their original countries, most fellowship recipients have obtained influential positions which they can use to help set the direction of research according to the training they received. In addition to this fairly conventional programme aimed at junior candidates, MNH has set up a quite different type of fellowship, which provides senior scientists and professionals with the opportunity to visit three or four centres working in their field. Travelling seminars complete the range of training-related activities. Over the years, about a thousand candidates and experts have participated directly in training activities organised by MNH.

Other innovative approaches In recent years MNH has started to extend its efforts in a new direction. Building on its previous work on legislation and guidelines, it has produced documents that develop innovative approaches to the provision of mental health care. Following the model of self-help groups, a decentralised network of services was recommended as the basis of the WHO ‘Initiative of Support to People Disabled by Mental Illness’ (WHO, 1988b). The common feature of the centres participating in this initiative, which has become the platform for important collaborative work, is represented by the importance given to consumer involvement in mental health activities and the awareness of the increasing importance of psychosocial rehabilitation. Several documents related to mental health care policy and to various aspects of mental health care have been issued thus far in the framework of this project (WHO, 1989, 1992a,b, 1993c,d). Documents on interventions to minimise the psychosocial consequences of natural and man-made disasters have also been produced, based on previous experience (WHO, 1991).

Future directions It is hoped that future MNH activities in the production of documents about policies and guidelines will progress in at least three directions:

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(a) towards an improvement in the quality of mental health services provided, and an extension of coverage to under-served populations (b) towards a stronger emphasis on the primary prevention of disease and disability (c) towards greater consumer involvement in the planning, implementation and evaluation of mental health care. The two greatest challenges for MNH lie in convincing policy makers and health administrators of the importance, aptness and cost-efficiency of these directions, and in finding the financial resources to develop projects and activities.

References BAKER , A., D AVIES , R. L. & S IVADON , P. (1959) Psychiatric Services and Architecture. PHP No. 1. Geneva: World Health Organization. CURRAN , W. J. & H ARDING , T. W. (1978) The Law and Mental Health: Harmonizing Objectives. Geneva: World Health Organization. ESSEX , B. & G OSLING , H. (1982) Programme for Identification and Management of Mental Health Problems. London: Longman. —— & —— (1983) An algorithmic method for management of mental health problems in developing countries. British Journal of Psychiatry, 143, 451–459. WHO (1975) Organization of Mental Health Services in Developing Countries. 16th Report of the Expert Committee on Mental Health. TRS No. 564. Geneva: World Health Organization. —— (1988a) Prevention of Mental, Neurological and Psychosocial Disorders. WHO/MNH/ EVA/88.1. Geneva: World Health Organization. —— (1988b) Initiative of Support to People Disabled by Mental Illness. WHO/MNH/MEP/ 88.6. Geneva: World Health Organization. —— (1989) Consumer Involvement in Mental Health and Rehabilitation Services. WHO/ MNH/MND/89.10. Geneva: World Health Organization. —— (1990a) Quality Assurance in Mental Health. WHO/MNH/MND/90.11. Geneva: World Health Organization. —— (1990b) Annotated Directory of Mental Health Training Manuals. WHO/MNH/MND/ 90.6. Geneva: World Health Organization. —— (1990c) Catalogue of Fellowships/Training Grants in the Fields of Psychiatry, Neurology and Allied Sciences. WHO/MNH/MND/90.7. Geneva: World Health Organization. —— (1991) Psychosocial Consequences of Disasters: Prevention and Management. WHO/MNH/ PSF/91.3. Geneva: World Health Organization. —— (1992a) Schizophrenia: Information for Families. WHO/MNH/MND/92.8. Geneva: World Health Organization. —— (1992b) Innovative Approaches in Mental Health Care: Psychosocial Interventions and Case Management. WHO/MNH/MND/92.11. Geneva: World Health Organization. —— (1993a) Essential Treatments in Psychiatry. WHO/MNH/MND/93.26. Geneva: World Health Organization. —— (1993b) Essential Drugs in Psychiatry. WHO/MNH/MND/93.27. Geneva: World Health Organization. —— (1993c) Transition from Hospital to Community: a Literature Review on Housing. WHO/ MNH/MND/93.17. Geneva: World Health Organization.

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—— (1993d) Innovative Approaches in Service Evaluation: Consumer Contribution to Qualitative Evaluation/Soft Indicators. WHO/MNH/MND/ 93.19. Geneva: World Health Organization. —— (1995) Guidelines for the Promotion of Human Rights of Persons with Mental Disorders. WHO/MNH/MND/95.4. Geneva: World Health Organization. —— (1996a) Mental Health Care Law: Ten Basic Principles with Annotations Suggesting Selected Actions to Promote their Implementation. WHO/MNH/MND/96.9. Geneva: World Health Organization. —— (1996b) Psychosocial Rehabilitation: a Consensus Statement. WHO/MNH/MND/96.2. Geneva: World Health Organization. —— (1996c) Psychiatry of the Elderly: a Consensus Statement. WHO/MNH/MND/96.7. Geneva: World Health Organization. —— (1998) Primary Prevention of Mental, Neurological and Psychosocial Disorders. Geneva: World Health Organization.

Experiences of a WHO consultant

Part V. A personal reminiscence

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15 Experiences of a WHO consultant ROBERT GIEL

The worries of a WHO consultant Usually the letter inviting you to act as a mental health consultant arrives well ahead of time, but without any firm commitment on the part of WHO. You hasten to confirm that you are free to take on the specified task at the stated time, and mark the dates in your agenda. Or you reply that, unfortunately, other matters prevent you from accepting the invitation. In the latter case there is no response, and in the former not for quite a long while. In the meantime, local requests start threatening to fill in the blank spaces in your agenda, and you grow increasingly worried about the details of travel to the distant or troubled places requested by WHO. Your beloved starts to shake her head, while you listen to the news about just those parts of our chaotic world that you are supposed to visit. In the ’70s and early ’80s your worries centred mainly on obtaining visas from distant consulates in time, and on the lack of convenient connections offered by the major airlines. In Egypt, for example, there was the choice between the comfortable ‘Magyar’, the express-train from Cairo to Alexandria, which involved an unpredictable taxi-ride at an undefined rate to the station in Cairo; a somewhat unreliable domestic flight; or, in later years, a trusty bus along the new desert road. More recently, your worries concerned the daily number of rockets over Baghdad; the curfews and the daily number of casualties in the Intifada in Gaza; or the problem of reaching badly shaken Yerevan in Armenia without having to stay overnight in crowded Moscow. Having managed Moscow without too much trouble, and 179

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after a prolonged wait at one of its many domestic airports, it was still possible to arrive at the wrong terminal in Yerevan – without a clue as to what had gone wrong. In the end, however, you invariably got to where you wanted to be, and with enough time to start worrying about the formalities of a timely and regular departure. By way of example, although I spent a week in Ankara during a WHO workshop, according to my passport I had never entered Turkey, due to a mix-up with the transfer in Istanbul. So I could not leave the country either, of course. Official attempts to solve this puzzle before my departure all failed; I would first have to fly to Istanbul in order to enter the country formally. On my last day in Ankara I waited with considerable apprehension at the migration desk in the airport, expecting to be arrested as a spy, until the immigration officer drew the only reasonable conclusion. He handed me back my unstamped passport and waved me through, deciding that I had never been in Turkey at all. A WHO laissez passer is, under such circumstances, a desirable attribute. These circumstances do not usually prevail in Europe, where the UN laissez passer is insufficient proof of your identity; but they did in Baghdad, where I tried to depart amidst a heavy throng of Egyptians and got completely separated from my Iraqi hosts, my luggage and finally my flight. The blue booklet turned me into a trustworthy person and a bit of a VIP, quite the opposite of how it is viewed at the Swiss border.

Consultant or adviser? The question is whether all these troubles are worthy of the assignments given by WHO. There is, in my experience, a subtle difference between assignments concerning Europe and those concerning the Middle East, Asia or Africa. In Europe, which is full of professionals and experts both inside and outside government circles, one is very rarely awarded the status of consultant. Instead, one acquires the less profitable status of temporary adviser. In Europe, a temporary adviser tends to be a specialist with a defined professional task, such as reporting on developments of a specific health problem or a particular type of health care. The adviser is never asked to give advice to the government of another European country, which has a hard enough time trying to bury the products of indigenous know-how under heaps of red tape. In the often more ancient cultures of the developing world, such as in the Middle East, Asia or Africa, the WHO consultant is a respected visitor who meets with little obstruction when he wants


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to pass on his advice to the highest authorities. Such is the prestige of the World Health Organization in those areas of the world. The success of the consultant depends on how able a listener he is, on his degree of preparedness and adaptability to the unexpected, and on his capacity to blend the ideas formulated by WHO with what he has learned from his hosts. In the next paragraphs I will describe just one sequence of WHO-sponsored events – to which I was a lucky witness – that prepared the ground for significant changes in the delivery of mental health care in the developing world. They form part of the unique series of my own life events sponsored by WHO; others will be able to tell similar tales.

WHO-sponsored events that really made a difference In 1972, while convening at the Regional Office in Alexandria, the Group Meeting on Mental Health listed serious deficiencies in the administration and organisation of mental health services, the delivery of mental health care, the utilisation and training of manpower, and mental health legislation and research in the countries of the Eastern Mediterranean Region (WHO, 1972). For each of these areas, broad objectives were formulated which were to be pursued without pause for the next 10 to 15 years. The Inter-regional Seminar on the Organization of Mental Health Services, held in Addis Ababa in 1973 (WHO, 1973), served to emphasise and elaborate on the guiding principles of mental health care. It resulted, after Carothers’ work on mental illness in Africa, in the second scientific publication by WHO on mental illness in the Third World (Baasher et al, 1975). It was a memorable occasion for the participants, who met Emperor Haile Sellassie – dethroned the following year. For the first time in history, the highest Ethiopian authorities took notice of the poor state of mental health care in their country. In 1975 many of those who took part in the Addis Ababa seminar met again in Khartoum, for the Seminar on the Application of Psychiatric Epidemiology (WHO, 1975a). The need for a more scientific basis for the planning of mental health services was discussed and accepted. In 1978, at the Co-ordinating Group Meeting on Mental Health in Alexandria, there was proof that significant developments had taken place (WHO, 1978). Two examples were mental health representation in the ministries of health, and mental health legislation.

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A milestone was reached in 1974 with the WHO Expert Committee on the Organization of Mental Health Services in Developing Countries, held in Geneva (WHO, 1975b). Here, each country was asked to formulate a national policy on mental health, and speakers emphasised the importance of integrating mental care into the general health services so as to reach out further into the community. At this meeting the seeds were sown for the successful WHO Collaborative Study on Strategies for Extending Mental Health into Primary Care (Sartorius & Harding, 1983). The core group of investigators were like a travelling circus for many years, touring Geneva, Khartoum, Dakar, Chandighar, Cali, Manila and Fayoum. This study had a significant impact in the developing world. In India, for example, its principles were incorporated into the national health policy. In Cali, Colombia, the circus met the wife of a sugar cane cutter, who was quite effective in managing the mentally ill in her village. She had no more than an elementary education, a few months of health promotion training, and a course on dealing with the serious mental health problems that had been selected as priorities. A map of the village pinned on the wall of her simple home located the families with her patients. She was supervised by psychiatrists from the University of Cali, and could give a fair account of the diagnosis and treatment of her cases. In the Fayoum district of Egypt, all physicians running the general health centres were trained in the management of the selected priority conditions. As a result, reported psychiatric morbidity in the area had risen sharply. And the Egyptian public health authorities had started to take notice of the plight of vagrants with psychoses. This collaborative study was officially concluded in 1981 during the WHO Study Group on Mental Health Care in Developing Countries in Geneva. The evaluation showed that it had been possible to define priority conditions according to predetermined criteria, to specify appropriate technology for the management of these conditions in primary care settings, to define the tasks to be undertaken by health workers and community members, and to provide them with effective training. In 1985 WHO decided to hold a meeting in Groningen to take stock of the achievements of this and similar attempts at introducing a mental health component into primary care. Its guiding principles, based on much deliberation and experience, were laid down in a document for future generations (WHO, 1990). The actions of a WHO Collaborative Study had thus been true to the words of a WHO Expert Committee from 1974! This type of WHO action kept up its momentum, even under severely adverse circumstances, as evidenced by what happened in Ethiopia. In


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December 1985 WHO sponsored a workshop in the town of Nazareth to formulate a national mental health programme for Ethiopia. For decades, the country had been dependent on one or two psychiatrists from Eastern Europe staffing an ancient mental hospital in Addis Ababa. In the early seventies these meagre resources had been strengthened by a university out-patient department staffed by one Ethiopian psychiatrist. Even though the country was being ravaged by draught and civil war, the vice-minister of health responded to the challenge posed by the WHO workshop and acted accordingly. Today, there are nine foreign-trained Ethiopian psychiatrists, who supervise some 90 locally-trained psychiatric nurses, staffing 16 psychiatric out-patient units in regional general hospitals all over Ethiopia.

A matter of people So far, my consultant story has unfolded as a matter of business-like meetings. First and foremost, however, it was a matter of people working together intensely towards a common goal. The proof of their success is that they started to look forward to seeing each other again. WHO is, in my experience, an effective network of people both inside and outside the organisation. Although I shall do an injustice to many friends in the network, I shall conclude by paying homage to the attributes of a chosen few – the people who, for many years, dominated the series of life events that I have described above. A tribute, then, to the quiet wisdom of Taha Baasher, the philosophical restraint of Naren Wig, the well-organised drive of Tim Harding, and finally, the intoxicating omnipresence of Norman Sartorius.

References B AASHER , T. A., C ARSTAIRS , G. M., G IEL , R., et al (1975) Mental Health Services in Developing Countries. WHO Offset Publication No. 22. Geneva: World Health Organization. SARTORIUS, N. & HARDING, T. (1983) The WHO Collaborative Study on Strategies for Extending Mental Health Care. I: The genesis of the study. American Journal of Psychiatry, 140, 1470– 1473. WHO (1972) Group Meeting on Mental Health. Alexandria, 4–7 September, 1972. Document EM/ MENT/49 EM/GR.MT.MH./17 EMRO 5403. Geneva: World Health Organization. —— (1973) Inter-Regional Seminar on the Organization of Mental Health Services. Addis Ababa, 27 November–4 December, 1973. Document EM/MENT/63 EM/SEM.ORG. MH.SERV./24 EMRO 5401. Geneva: World Health Organization. —— (1975a) Seminar on the Application of Psychiatric Epidemiology. Khartoum, 17–21 February, 1975. Document EM/MENT/71 EM/SEM.APPL.PSY.EPID./15 EM/ICP/ MNH/002. Geneva: World Health Organization.

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—— (1975b) Organization of Mental Health Services in Developing Countries. Sixteenth Report of the WHO Expert Committee on Mental Health. Technical Report Series 564. Geneva: World Health Organization. —— (1978) Co-ordinating Group Meeting on Mental Health. Alexandria, 22–24 November, 1978. Document EM/MENT/90 EM/CO.MH. GM./12. Geneva: World Health Organization. —— (1990) The Introduction of a Mental Health Component into Primary Health Care. Geneva: World Health Organization.

Index

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Index Compiled by LINDA M. ENGLISH ABC Schizophrenia Study 94, 97 adolescence see childhood and adolescence affective disorders, biological research on 104–106 African Mental Health Action Group 157 alcohol dependence syndrome 139 Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) 15, 32–33, 41, 144 alcohol misuse 5, 125, 138–139 assessment 33–34, 36, 40, 66 biological research 107 ‘brief interventions’ project 140 ‘community response’ project 140–141 epidemiology 88–89 legislation 142–143 as public health problem 139–141 Alcohol Use Disorders Identification Test (AUDIT) 66, 140, 141 aldehyde dehydrogenase (ALDH) 88, 107 Alma Ata Declaration (1978) 156 American Psychiatric Association 32, 41 amitriptyline 104, 107 amphetamine-like substances 143 AMRO/WHO initiative to restructure psychiatric care in Latin America 161–171 antidepressants, research on 104–105, 106, 107 Asian populations and alcohol dependence 107 assessment instruments 32, 65–84, 127–128 see also individual names asylum psychiatry 50

behavioural science learning modules 128–129 benzodiazepines 106, 143 bio-behavioural approaches to mortality and morbidity in childhood 120–121 biological markers of depressive disorders 105

biological psychiatry 4 research 103–109 v. psychosocial approach 52, 55–56 biopsychosocial model 49 bipolar disorder 104 bullying in schools 126

CAPSE (computer-assisted PSE) 75 Caracas Declaration 161, 162, 164, 167 Catalogue of WHO Psychiatric Assessment Instruments 65 CATEGO program 23–24, 29, 73 CATEGO S+ diagnosis 94–95 Child Care Facility Schedule (CCFS) 66, 123 childhood and adolescence 66, 107–108, 117–126 bio-behavioural approaches to causes of mortality and morbidity 120–121 children in institutions 118, 119, 123 health promotion in adolescence 124–126 health promotion in early childhood 121–123 and ICD classification 20, 38, 40 mental and emotional problems 123–126 planning for child mental health 118–120 psychosocial development 117–118 school mental health 126 China 31 CIDI see Composite International Diagnostic Interview cigarette smoking 125, 147 classification, developments in 3–4, 6, 15, 17, 19–21, 32, 48, 89–90 see also Diagnostic and Statistical Manual and International Classification of Diseases Clinical Screening Procedure (CSP) 66 cognitive impairment in elderly 106, 132, 133, 134–135

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Cognitive/Neuropsychological Assessment Schedule 66–67 Collaborating Centres 7, 62 colour blindness 104 ‘common language’, development of 16, 21, 36, 48, 77, 136 communication skills in adolescence 124, 125 in health workers 128–129 community-based care: introduction in Latin America 161–171 Composite International Diagnostic Interview (CIDI) 14, 33–36, 58, 67–69, 79–84 Appendix, 145 Computerised CIDI (CIDI Auto) 68 Post-traumatic Stress Disorder Module (CIDI–PTSD) 68 Primary Health Care Version (CIDI–PHC) 68 Substance Abuse Module (CIDI–SAM) 68 computers and information transfer 57–58 consensus statements 61, 173 consumer involvement 174, 175 controlled drugs 141, 143 Convention on the Rights of the Child (1989) 121 Copenhagen conference (1982) 32–33, 36 cultural and environmental factors 4, 53, 128 day care for children 123 deinstitutionalisation 51–52 dementia 106, 132, 133, 134, 135 depression 5–6, 21, 59 assessment 76 biological research 97, 104–106, 107 and dementia 133 in primary care 8 Determinants of Outcome of Severe Mental Disorders (DOSMED) study 6–7, 20–22, 25, 26, 27–31, 92–94 developing countries 173 child mortality rates 120–121 development of mental health programmes 153–160 Latin America 161–171 mental health consultants 180–181 neurological disorders in 110 primary care in 7–8, 58, 60–61, 123–124, 155–157, 159, 182 schizophrenia in 6–7, 25, 28–29, 98–99

training for doctors in 58–59, 62–63 training manuals for use in 60, 124 dexamethasone suppression test 105 diagnosis, developments in 5–6, 21–27, 32, 48 Diagnostic and Statistical Manual (DSM) DSM–III 48, 54, 90 DSM–IV 33, 34, 35, 36, 40–41, 48, 52–53, 67, 71 diagnostic flow charts 60 Diagnostic Interview Schedule (DIS) 32, 33, 34 disability 8, 20–21, 69–70, 90, 99, 122–123, 135, 163 Disability Assessment Schedule (DAS) 69–70, 90, 94, 99, 135 documents produced by WHO 38–39, 172–176 dopaminergic neurotransmission 97 drug and substance misuse 5, 33–34, 36, 125 CAR study 40, 144–145 CIDI Substance Abuse Module 68 international collaboration 144–146 legislation 142–143 prevention and control 138–149 see also alcohol misuse drug treatment research 104–105, 106 elderly 106, 132–137, 173 contribution of Norman Sartorius 135–137 and demographic changes 132 ICD–10 and health of 134–135 WHO’s work for health of 132–133 epidemiology 3–4, 15, 17–18 historical notes 89–90 of neurological disorders 112 prerequisites for worldwide comparative studies 88–89 of psychiatric disorders in Latin America 162–164 of schizophrenia 91–102 training programmes in research techniques 31 WHO programme 90–91 epilepsy 111, 113 Ethiopia 181, 182–183 Europe, temporary advisers in 180 fellowships 62–63, 113, 174 functional psychopathology 55

Index general practice see primary care genetic research 4, 54, 104 Geriatric Mental State Examination 133 gingko biloba 107 guidelines produced by WHO 173 health promotion 9–10, 164 in adolescence 124–126 in early childhood 121–123 health workers: training in behavioural science 128–129 history of epidemiology 89–90 historical–political context in Latin America 164–165 of modern psychiatry 50–52 human rights 9, 165, 172 ICD see International Classification of Diseases ICD–10 Symptom Checklist for Mental Disorders 39, 70 ICD–10 Symptom Glossary 39, 70 imipramine platelet binding sites 105 immunisation 120–121 India 158 infectious diseases 110, 119, 120 information transfer see mental health information transfer Initiative for Restructing of Psychiatric Care in Latin America 161–171 International Classification of Diseases (ICD) 6, 16, 113 ICD–8: 19–20, 90–91 ICD–9: 19–20, 21, 36, 40, 94, 113 ICD–10: 14, 33, 34, 35, 48, 67, 69, 71 Clinical Descriptions and Diagnostic Guidelines (CDDG) 37, 134, 144 development of Chapter V 36–37 Diagnostic Criteria for Research (DCR–10) 38, 134, 144 and drug misuse 40, 144 family of documents 37–41 and health of elderly 134–135 and practice of psychiatry 52–53 primary health care version (ICD–10 PHC) 9, 21, 38, 39, 57–58, 60–61 relationship to DSM–IV 40–41 Symptom Checklist for Mental Disorders 39, 70 Symptom Glossary 39, 70

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International Personality Disorder Examination (IPDE) 14, 33, 35–36, 71, 79 Appendix, 81 Appendix, 84 Appendix International Pilot Study of Schizophrenia (IPSS) 6, 21–27, 29, 30, 91–92, 98, 99 Kraepelinian classification system 89–90 language and translation issues 24–25, 59 Latin America: AMRO/WHO initiative to restructure psychiatric care 161–171 epidemiological basis for action 162–164 evaluation 169–170 historical–political context 164–165 implementation 167–169 regional programmatic basis for action 166–167 technical basis for action 165–166 WHO’s mental health programme 164 learning disability 4, 38, 40 learning materials produced by WHO 173–174 Lebenswelt concept 56 legal rights of patients 9, 165, 172 legislation, WHO documents on 9, 142–143, 172 Life Events Schedule (LES) 71–72 life skills education in schools 124–126 malnutrition 9, 110, 119, 120 medical model 48, 49–50 medicine and psychiatry 49–50 Mental Disorders in General Health Care study 61 mental health consultants: personal reminiscence 179–184 mental health information transfer 57–64 achievements in primary care 59–61 by computer 57–58 consensus statements 61 inside people’s heads 61–63 by printed word 59–61 by television 58–59 mental health legislation 9, 142–143, 172 mental health programmes, regional and national 151–176 community involvement 159 comprehensiveness 158 development 153–160

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emergence and features of national programmes 157–159 emergence of mental health as public health issue 153–155 impact of primary health care approach 155–157, 159 in Latin America 164, 166–167 multi-sectoral nature 158 tribute to Norman Sartorius 159–160 mental hospitals 161, 165–166 mental retardation 4, 38, 40 mild cognitive disorder 134–135 mortality rates 120–121 mother–infant relationship 122 naloxone 106 neurocognitive abnormalities, study of 55 neuroleptics 106 neurosciences programme for control of neurological disorders 110–114 oestrogen levels 97 XXIII Pan American Sanitary Conference (1990): Resolution XIII 166–167 Pathways Interview Schedule 72 patients’ rights 9, 165, 172 Personality Disorder Examination (PDE) 32, 33 personality disorders 35, 71 personal reminiscence 179–184 pharmacological treatment research 104–105, 106 post-traumatic stress disorder 68 Present State Examination (PSE) 6, 22–24, 32, 72–73, 92, 98, 99 PSE–9: 33, 34 PSE–10: 34, 73, 74 prevention of mental disorders 9–10, 164, 175 drug and substance misuse 138–149 guidelines on 173 primary care 5, 75–76, 182 achievements in information transfer 57–58, 59–61 CIDI Primary Health Care Version 68 as cornerstone for mental health care 7–9 and drug misuse 142 impact of concept on mental health programmes 155–157, 159 in Latin America 161, 165

primary health care version of ICD–10: 9, 21, 38, 39, 57–58, 60–61 and problems in children 123–124 and training 58–60, 124, 173–174 programmes A, B, C and D 15, 16–17, 18–31 A 16, 19–21, 48 B 16, 21–27 C 16, 27–31 D 16, 31 PSE see Present State Examination pseudodementia 106 psychiatry, contemporary issues in 47–56 psychoactive substance use see alcohol misuse and drug and substance abuse Psychological Impairments Rating Schedule (PIRS) 73, 90, 94 psychosocial aspects of health 117–131, 155 ‘psychosocial nutrition ‘ 122 psychosocial rehabilitation 173, 174 psychotherapy and psychoanalysis 4–5, 51, 89–90 psychotic states, assessment of 73–74 psychotropic drugs misuse 139, 143–144 research on effectiveness 104–105, 106 quality of life assessment 127–128 Quick CIDI 68 Sartorius, Vera 136–137 SCAN see Schedules for Clinical Assessment in Neuropsychiatry Schedules for Clinical Assessment of Acute Psychotic States (SCAAPS) 73–74 Schedules for Clinical Assessment in Neuropsychiatry (SCAN) 14, 33–36, 73, 74–75, 79–84 Appendix, 145 schizophrenia 5–7, 106, 107 in developing countries 6–7, 25, 28–29, 98–99 and disability 20–21 DOSMED study 6–7, 20–22, 25, 26, 27–31, 92–94 epidemiology 91–102 and ICD–10/DSM–IV 53–55 International Pilot Study of Schizophrenia (IPSS) 6, 21–27, 29, 30, 91–92, 98, 99 schools life skills education in 124–126 and mental health 126, 159

Index Scientific Group on Mental Health Research report (1964) 3–5, 8, 18, 103 Self-Reporting Questionnaire (SRQ) 75–76 sleep-EEG abnormalities 105 smoking 125, 147 social field theory 89 somatic prejudice in psychiatry 55–56 Somatoform Disorders Schedule (SDS) 69 Somatoform Disorders Symptom Checklist 70 Standardised Assessment of Depressive Disorders (SADD) 76 substance abuse see alcohol misuse and drug and substance abuse television and information transfer 58–59 temporary advisers in Europe 180 training in behavioural science 128–129 in biological research 107 in childhood problems 124 in epidemiological research techniques 31 fellowships 62–63, 113, 174 manuals 59–60, 124, 173–174 in neurological disorders 113 in primary care 58–60, 124, 173–174 WHO documents on 173–174 United States, epidemiology in 89–90 University of Michigan Version of CIDI (CIDI–UM) 68

189

university psychiatry 50 urbanisation, effects of 163 US/UK Diagnostic Project 5–6, 22–23 videotapes, instructional 58–59 violent behaviour 162–163 WHO–ADAMHA Joint Project 15, 32–33, 36, 144 WHO Collaborative Study on Strategies for Extending Mental Health Care 60, 76, 182 WHO consultants: personal reminiscence 179–184 WHO Coordinated Study on the Long-term Course and Outcome of Schizophrenia 98 WHO documents 172–176 WHO Expert Series on Biological Psychiatry 107 WHO neurosciences programme for control of neurological disorders 110–114 WHO Psychiatric Disability Assessment Schedule (WHO/DAS) 69–70, 90, 94, 99, 135 WHO Psychological Impairments Rating Schedule (WHO/PIRS) 73, 90, 94 WHO Quality of Life instrument (WHOQOL) 127–128 WHO Quality of Life Project 127–128 women, role of 167

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Index


Promoting Mental Health Internationally

Promoting Mental, Emotional, and Social Health: A Whole School Approach

Promoting Health for Working Women

Religion and Mental Health

Spirituality and Mental Health

Primary Care Mental Health

Teaching Mental Health

The Mental Health Handbook

Mental Health and Disasters

Disasters and Mental Health

Psychiatric-mental health nursing

Teamworking in Mental Health

Confidentiality and mental health

Mental Health and Inequality

Migration and Mental Health

Psychiatric-mental health nursing

Mental Health Outcome Evaluation

Appalachian Mental Health

Disasters and Mental Health

Mental Health Financing (Mental Health Policy and Service Guidance Package)

Mental Health Context (Mental Health Policy and Service Guidance Package)

Salem Health: Psychology & Mental Health

Mental Health Disorders Sourcebook (Health Reference Series)

Mental Health Services: A Public Health Perspective

Exercise, Health and Mental Health: Emerging Relationships

Promoting Health and Wellbeing through Schools

Vital Notes for Nurses: Promoting Health

Mental Health and Care Homes

Mental Health Reform (Point Counterpoint)

Critical Perspectives on Mental Health

Promoting Mental Health Internationally

Promoting Mental, Emotional, and Social Health: A Whole School Approach

Promoting Health for Working Women

Religion and Mental Health

Spirituality and Mental Health

Primary Care Mental Health

Teaching Mental Health

The Mental Health Handbook

Mental Health and Disasters

Disasters and Mental Health

Psychiatric-mental health nursing

Teamworking in Mental Health

Confidentiality and mental health

Mental Health and Inequality

Migration and Mental Health

Psychiatric-mental health nursing

Mental Health Outcome Evaluation

Appalachian Mental Health

Disasters and Mental Health

Mental Health Financing (Mental Health Policy and Service Guidance Package)

Mental Health Context (Mental Health Policy and Service Guidance Package)

Salem Health: Psychology & Mental Health

Mental Health Disorders Sourcebook (Health Reference Series)

Mental Health Services: A Public Health Perspective

Exercise, Health and Mental Health: Emerging Relationships

Promoting Health and Wellbeing through Schools

Vital Notes for Nurses: Promoting Health

Mental Health and Care Homes

Mental Health Reform (Point Counterpoint)

Critical Perspectives on Mental Health

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