Books & Electronic Media

The world health report 2001 — Mental health: new understanding, new hope

Geneva, World Health Organization, 2001.
ISBN 92 4 156201 3, ISSN 1020-3311, 178 pages.
Price: Sw.fr. 15, Sw.fr. 10.50 in developing countries.

Fifty years ago, in one of the first and best major WHO reports, the psychiatrist, John Bowlby, deplored the "lack of conviction on the part of governments, social agencies, and the public that mother-love in infancy and childhood is as important for mental health as are vitamins and proteins for physical health" (Bowlby J, Maternal care and mental health, WHO Monograph Series No 2, 1952: 158). A great deal of attention has since been paid to the centrality for mental health of love, or what Bowlby and his followers call "attachment".

This aspect of mental health does not feature prominently in The world health report for 2001, however. It begins by reiterating the commitment of WHO to health as "not merely the absence of disease or infirmity" but "a state of complete physical, mental and social well-being". And it bravely concludes: "For rich and poor alike, mental well-being is as important as physical health". In the intervening pages, though, the report, as its authors admit, "focuses upon mental and behavioural disorders rather than the broader concept of mental health". Adopting this focus, they note that surveys across the world indicate that "during their entire lifetime, more than 25% of individuals develop one or more mental or behavioural disorders". This has accordingly been taken up in press headlines proclaiming, for instance, "WHO says 1 in 4 get mental illness" (Boseley S, The Guardian, 5 October 2001, p. 15).

Beginning with neurological and other biological correlates of mental illness, and with unreferenced assertions about its genetic determinants, the report proceeds, in effect, to detail a damage-limitation programme in which first place is given to medication, and second and third place to psychotherapy and psychosocial rehabilitation, focusing for instance on teaching "coping skills". But the medicines it advocates do not cure the conditions it considers from the International statistical classification of diseases and related health problems (ICD-10). Rather, as the report's authors admit, the medicines they consider seek simply "to reduce or control their [these diseases'] symptoms or to prevent relapse".

The priority the report gives to medication, or "pharmocotherapy", might be justified in alleviating epilepsy. Perhaps that is why the authors, whilst acknowledging that it is anachronistic and unjustifiably stigmatizing to call epilepsy a mental illness, nevertheless include it in their report. Pharmocotherapy is also arguably crucial to alleviating schizophrenia, but it would have been good if the report had not downplayed, in the interest of cost, the value of some of the newer psychiatric medications. These can avoid the crippling Parkinsonian side-effects resulting from long-term use of cheaper and accordingly more readily available antipsychotic medication. It is a pity, too, that the report, again perhaps because of cost, does not emphasize the value of recently developed cholinergic receptor agonists in reversing the cognitive and attention deficits of Alzheimer's disease. Nevertheless it is good to see the authors recommending ways of circumventing the prices charged by drug companies by using non-profit-making suppliers.

The priority the report gives to drug treatment for chemical dependence is much less justified — indeed it seems unjustifiable, except as a way of providing a possibly more controllable substitute in the case of substance abuse. Alcholism, as the authors recognize, is susceptible to "cultural and religious values" and by "the community reinforcement approaches" of consumer movements such as Alcoholics Anonymous. Nor will drugs do much for mental deficiency, some of which can be prevented by iodizing salt and counselling parents; where it is not prevented it can be compensated for to some extent by training, sheltered settings and care.

Most importantly, drug treatment seems entirely ill-suited to allaying depression. Describing it in terms of the ICD-10 as characterized by "sadness, loss of interest in activities, and decreased energy", the report observes that this condition is now "the fourth leading cause of burden among all diseases". It goes on to survey various causes and correlates of depression: poverty; domestic and sexual violence; old age; physical illness; racial and other discrimination (including discrimination against those with HIV/AIDS); and internal and external displacement and migration due to natural or man-made catastrophes and disasters. Not surprisingly, research reported last year in this journal found that the option least favoured by those seeking help for depression was "medicine or tablets" (Andrews et al. The persistence of the burden of anxiety and depression, Bulletin of the World Health Organization, 2000, 78: 449). Unsurprising too is the finding of the current World health report that the relapse rate for depression is worse for those treated with antidepressant medication than for those treated with cognitive behavioural therapy.

Just as Bowlby and his followers of today have found that mental health is correlated with secure attachment, they have also found that mental ill-health — particularly depression — is correlated with insecure attachment, separation, and loss. The authors of the report are therefore to be congratulated for emphasizing the need to counter the separation and loss involved in stigmatizing, discriminating against, and secluding people with mental illness. But if the main aim is to increase the availability of primary care devoted to making "psychotropic drugs ... constantly available at all levels of health care" the report does not quite deliver on its offer of "new understanding, new hope". Medication often provides some hope, of course, and facilitates a quick turnover, but it can also help to put the need for understanding out of sight. From this point of view we can continue to deplore "the lack of conviction of governments, social agencies, and the public" about the importance for mental health of attachment and love.

Janet Sayers

Professor of Psychoanalytic Psychology
School of Social Policy, Sociology and Social Research
University of Kent, Canterbury
Kent CT2 7NY, England
(email: jvs@ukc.ac.uk)