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					Action on mental health:
   a review of international policies


                 Iain K Crombie
                   Linda Irvine
                 Lawrence Elliott
                 Hilary Wallace




 Commissioned and funded by NHS Health Scotland

                   June 2005
                        Iain K Crombie1
               Professor and Head of Department

                         Linda Irvine1
                        Research Fellow

                       Lawrence Elliott2
                          Professor

                        Hilary Wallace1
                       Research Assistant




                   1
                    Section of Public Health
                     University of Dundee
            Division of Community Health Sciences
                      Mackenzie Building
                      Kirsty Semple Way
                            Dundee
                          DD2 4BF


      2
          Centre for Integrated Healthcare Research and
                the School of Community Health
                        Napier University
                      Comely Bank Campus
                      13 Crewe Road South
                            Edinburgh
                            EH4 2LD




                        Contact details:

                  Professor Iain K Crombie
                  Tel: + 44 (0)1382 420102
             Email: i.k.crombie@chs.dundee.ac.uk




This report is based on documents available up to May 2005


                               2
Table of contents
Acknowledgements                                                 4
Caveat                                                           5
Executive Summary                                                6

Section 1: Study Design
       Introduction                                             12
       Aims                                                     14
       Methods                                                  15

Section 2: Overview of Mental Health Policy
       Documents on mental health                               18
       Deinstitutionalisation of mental health services         20
       Mental health                                            22
       Mental ill-health                                        23
       Scale of the problem                                     25
       Causes of mental health problems                         28
       Human rights                                             32
       Principles                                               34
       Goals and targets                                        35
       Development of Public Mental Health Policy:
              Case studies from Australia and New Zealand       38
       Mental Health Declaration and Action Plan for Europe     46

Section 3: Strategic Approaches to Mental Health Problems
       Overview                                                 48
       Development of mental health policy and strategy         49
       Mental Health Promotion                                  50
       The wider determinants of mental health and wellbeing    55
       Provision of services                                    57
       Children and young people                                61
       Older people                                             66
       Carers                                                   69
       Non-governmental organisations                           71
       Stigma and discrimination                                73
       Suicide                                                  81
       Attempted suicide and deliberate self harm               91
       Depression                                               93

Section 4: Evaluation                                           98

Section 5: Commentary                                          102

References                                                     110

Appendix 1                                                     123
Appendix 2                                                     144




                                        3
Acknowledgements
We are grateful to NHS Health Scotland for providing the funding which gave us the
opportunity to carry out this work. We would like to thank Dr Laurence Gruer, Jackie
Willis, Jill Muirie and Erica Wimbush for their support during this work. We are also
very grateful to those countries who kindly supplied us with paper copies of their
policies.




The opinions expressed in this publication are those of the researchers and not
necessarily those of the NHS Health Scotland.




                                         4
Caveat
This report is based on the extensive set of documents we were able to obtain from
web sites, individuals and government departments. Most documents were obtained
from government department websites, particularly those of the Ministries of Health.
To maximise coverage, the web was searched in a variety of ways and individual web
sites were visited several times. However we cannot be certain that we obtained all
relevant documents. Further, for several countries it is likely that some documents
have not been translated into English.    Thus, some of our findings might well be
modified had we had access to a fuller set of documents.


Policy documents relevant to mental health can be conveniently grouped into overall
health policy, overall mental health policy and topic specific mental health policies.
In addition, many supporting documents in the form of background papers, reports
and commentaries that have informed policy were obtained.             The number of
documents is truly vast so that, although all were reviewed, not all can be mentioned
here. Instead selected documents are cited to identify the range of approaches which
have been taken. The absence of a country from any section of this report should not
be interpreted as indicating the absence of policy documents on that topic. Instead the
presumption should be that, with a few exceptions, most countries cover most of the
topics.




                                          5
Executive Summary
Introduction
Mental health is recognised to be a major public health issue: the World Health
Organisation estimates that mental health problems account for 12% of the global
burden of disease. This study reviews public mental health policies in fourteen
developed countries to establish the nature and range of policy, the goals that are set
and the strategic approaches adopted to achieve these goals.


Methods
Current Public Health Policies and other relevant documents from fourteen developed
countries were reviewed. The countries were Australia, Canada, Denmark, England,
Finland, Ireland, Japan, New Zealand, Northern Ireland, Norway, Scotland, Sweden,
USA and Wales. Documents were obtained by extensive searching of websites,
particularly those of governments, and by writing to Ministries of Health. The
documents were reviewed by two independent observers.

Results
Most countries have extensive documentation on mental health, comprising separate
policy and supporting documents. There is a marked variation between countries in
the topics which these documents address. All countries recognise that mental health
is a major problem, with estimates that up to 20% of the population will experience
mental health problems each year. However the countries use different definitions of
mental health problems so that direct comparisons are not possible. Further there are
few estimates of the health care costs or the social and economic costs of mental
health problems.


Most countries review the causes of mental health problems, in particular the major
role played by the physical, social and economic environments. Adverse
circumstances can lead to stress, poor quality relationships and social isolation. These
factors can increase the risk of mental health problems. Life events, such as
unemployment, divorce and bereavement can also contribute to the development of
problems. It is clear that many of the determinants of mental health problems lie



                                           6
outside the ambit of health care. This presents a challenge for mental health policies
which are issued almost exclusively by departments of health.


Unusually for public health policy most countries discuss the principles on which
mental health policy should be based. These derive from concerns about the violation
of the human rights of people with mental health problems. Thus the principles
emphasise the rights of the individual to high quality compassionate care and the
opportunity to enjoy a full and fulfilling life.


Most countries have three overarching goals: to improve overall wellbeing; to
improve mental health care services; and to reduce the prevalence of mental disorders
and the impact of these disorders on consumers. However there are few specific
targets for desired improvements in mental health and those stated differ markedly
between countries. Only two countries, Northern Ireland and Wales, set numerical
targets for improvements in general mental wellbeing. Many countries are currently
developing indicators to monitor wellbeing, mental health problems and service
delivery. Australia has a well developed set of indicators covering process and
outcome measures in a range of settings.


Deinstitutionalisation of the psychiatric services was a landmark development in
mental health services. Some countries began this in 1955 while others delayed it for
10, 20 or even 40 years. Most countries recognise that insufficient resources were
transferred to the community to support deinstitutionalisation, and that underfunding
of services remains a problem. Thus there is considerable attention to increase the
resources for mental health services and to improve their quality. As part of this there
is a drive to develop coordinated planning and delivery of services, to improve
training of all relevant professional groups and to ensure coordination across all
services. Other key issues addressed in mental health policy are: mental health
promotion, stigma, suicide, the wellbeing of carers and the involvement of users and
carers in service planning and delivery. In addition many countries express the need
for further policy development, particularly to incorporate mental health issues into
planning at national, regional and local levels.




                                             7
Mental health promotion is given the central role in delivering the mental health
agenda: the aims being set for it are broadly the same as the overarching goals of
mental health policy. These will be achieved by actions to strengthen both individuals
and communities and by reducing barriers which those with mental health problems
face in gaining access to employment, education and other services such as housing.
The actions will take place across a range of settings, many of which are outwith the
control of healthcare. Particular emphasis is placed on the role of schools although
the family, the community, the workplace, the health and welfare systems and the
media are also seen as important. Policies recognise that enthusiastic support is
needed from individuals in each of these settings, but little detail is given on how this
will be engendered. Actions to be undertaken are often phrased in general terms with
few specific proposals being made. Some policies recognise that further research is
needed to identify specific opportunities for action and to develop effective
interventions.


All countries agree that the stigma surrounding mental illness and the consequent
discrimination must be tackled. However the nature of stigma is seldom defined and
its underlying causes are not well described. Several countries have run high profile
anti-stigma campaigns through information giving and awareness raising. Evaluation
of these found improvements in attitudes in New Zealand and Scotland. However an
independent evaluation of attitudes towards people with mental health problems in
England found a deterioration of attitudes.       New Zealand, which has the most
extensive campaign, acknowledges the need for the development and implementation
of novel strategies.


The considerable contribution that non-governmental organisations make to mental
health is widely recognised in policy. Several countries recognise that the funding of
these organisations is often inadequate and thus make proposals for increased and
more secure funding. There is also general acceptance of the need for improvement in
the relationship between the statutory and voluntary sectors.


Many policies focus on groups who require special attention. Children are important
because untreated mental health problems in childhood can impact on education, can
affect social skills and in some cases continue into adult life. Strategies to tackle


                                           8
problems in childhood include anti-bullying policies, increased staff training and
improving the coordination between services. The mental health problems which
beset older people are given priority for two reasons: they are an increasing and often
unrecognised set of problems: and often carry a high burden of care. There is concern
for the mental health of people who care for those with any chronic illness or
handicap. They make a major contribution but also have special needs such as
training, household modification and arrangements for short term breaks. The role of
carers for people with mental health problems is also highlighted. Many countries
aim to involve users and carers in the planning and delivery of services.


Policy on suicide is particularly well developed, with several countries having
separate policy documents to address it. In contrast to policies on other aspects of
mental health, policies on suicide typically review the scale of the problem and the
main risk factors as well as those groups at particular risk of suicide. A range of
interventions is proposed including: mental health promotion in high risk groups;
education to assist in early detection and to encourage early help seeking behaviour;
reducing access to means; improving media portrayal of suicide; improvements in the
management of crises; and long term care as well as the support for those affected by
suicide. Despite these many proposals several countries recognise the urgent need for
further research to develop effective interventions. Deliberate self harm is mentioned
as a risk factor for suicide. Other than this, although it is a common problem, policies
make little mention of deliberate self harm or its extent and few interventions are
proposed to tackle it.


Depression is the most prevalent mental health problem, so it is surprising that there is
little mention of it in policy documents on mental health. Although not explicitly
stated in policies, the proposed efforts to improve wellbeing may reduce the
prevalence of depression. Few other actions are proposed: for example there is little
attention to early detection or to improved treatment of depression. Only Australia has
a policy document on tackling depression. This identifies several areas for action
including raising community awareness and knowledge of depression; screening for
high risk individuals; improved training on depression for health professionals; and
early intervention.



                                           9
There is also little mention of other mental illnesses such as schizophrenia, anxiety
disorders or eating disorders. The USA gives details of the prevalence and
consequences of these disorders. Although other countries make occasional mention
of them only limited detail is given. There are very few specific proposals for
interventions to tackle the problems posed by these illnesses: either to prevent them,
to improve their management or to reduce the consequence to the individuals, or to
their families.


Conclusions
Mental health is addressed in many policy documents in most countries, many of
which have been published recently. It is clear from policy documents that mental
health represents a vast and varied set of topics. The need for further policy
development is recognised, particularly to establish the infrastructure to oversee and
ensure the delivery of effective interventions. Less recognised is the need for more
attention to the current Cinderella topics of depression and deliberate self harm. The
needs of specific groups in society, such as the socially disadvantaged, ethnic
minorities and prisoners, could be treated more systematically across the range of
mental health problems.


Mental health policy faces a number of challenges. Mental health problems are
common, highly varied in nature, and have a complex set of causes. Thus tackling
them requires a wide ranging set of interventions which need to be delivered by
professional groups and key individuals from all sectors of society. Ensuring that
mental health is a priority for all these stakeholders is an issue still to be resolved. The
common and continuing problem of stigma exacerbates mental health problems and
impedes the delivery of the mental health agenda. Finally, increased investment in
mental health services will be required to ensure that current need is adequately met.
It is to be hoped that the current prominence of human rights in mental health policy
will lead to increased activity in all sectors to confront the problems posed by mental
health.




                                            10
 Section 1:

Study Design




     11
Introduction
Mental health problems have a long and difficult history. Kotteck suggests that the
most famous case in the Bible is that of King Saul who was plagued by an evil spirit1.
Mental illness was recognised in classical Greece and was explained by the then
conventional medical model of the four humours2. However there was also a
philosophical perspective in which mental illness was seen as an arising from a
tormented soul3. The Greek views were adopted in the Middle Ages: one authority
wrote that mania arose from the harmful effects of yellow bile on the brain. The idea
of madness as moral perversion also persisted3, although a review by Kroll suggests
that sin was not often thought to be the cause of mental illness4. The origins of
present day psychiatry is usually traced to the 18th Century and the Age of
Enlightenment2.


Hospitalisation has been used to cope with mental illness for several centuries. The
first institutions for the care of those with mental health problems were developed by
the Muslims in the 9th and 10th centuries5. Possibly the most notorious asylum,
Bedlam, was founded in 1247 as the Priory of St Mary of Bethlehem, a general
hospital for the poor. By 1403 it housed six insane men among other patients,
gradually becoming almost exclusively for those with mental health problems and in
the process corrupting its name to Bedlam6. However at that time the care of most
people with mental health problems was given by their families or local
communities7. It was not until the 19th Century that it became a widespread practice to
lock away in asylums those with mental problems8 9. The process has been well
documented in the United Kingdom: in 1827 just over 1000 people with mental health
problems were treated in hospital; by 1900 this had risen to 74,000 and by 1959 to a
peak of 155,70010.


The 1950s witnessed the beginning of a major change in the management of mental
illness. These changes, which took place during the second half of the 20th Century
are thought to have occurred due to three largely independent factors11. In the first
instance, treatments for mental disorders became more widely available. New drugs,
particularly antidepressants and neuroleptics, aided the recovery of people with
mental disorders and pychosocial interventions were also introduced. Secondly, the



                                          12
human rights movement came into being with the creation of the United Nations in
1945. The human rights movement necessitated improvement in the management of
people with mental illness, many of whom had received poor care within psychiatric
asylums. Finally, mental health was incorporated into the concept of overall health as
defined in the World Health Organisation (WHO) constitution of 194612. WHO‟s
widely known definition of health “a state of complete physical, mental and social
wellbeing” put mental health firmly on the agenda for achieving overall health.


The WHO suggests that until recently actions to reduce the burden of mental illness
focussed on the management of mental illness13. Little effort was made to prevent
mental illness as the concept of mental health was traditionally not embraced within
public health. Many countries are currently striving to bring mental health from the
periphery to a prominent position in health policy14. To determine how far this
process has been taken, this study conducted a review of international policies on
public mental health in selected developed countries.




                                          13
Aims
This study provides a review of public mental health policy in fourteen developed
countries and investigates how policies describe and address the problems associated
with mental ill-health. The aims of the study were to:
i      Establish the nature and range of policy documents on mental health
ii     Identify current perspectives on the nature of mental health problems
iii    Describe policy views on the causes and scale of mental health problems
iv     Review the goals for improving mental health and the targets to be monitored
v      Outline strategic approaches which have been proposed to improve mental
       health and tackle mental health problems




                                          14
Methods
Policy documents on mental health were obtained from fourteen developed countries:
Australia, Canada, Denmark, England, Finland, Ireland, Japan, New Zealand,
Northern Ireland, Norway, Scotland, Sweden, USA and Wales. The majority of
documents were obtained from Ministry of Health websites.           The public health
policies from the USA, Japan, Denmark and the Health Strategy, the Health
Promotion Strategy and a report on suicide prevention from Ireland were obtained
directly from the Health Departments of each country.


Some countries have a limited number of documents in the English language available
on government websites. For example, Norway‟s public health strategy is only
available as a summary document in English. In addition, we found little English
language documentation from Finland and Sweden. We identified some relevant
documents that were not available in English on their government websites. We
therefore contacted the Ministries of Health of Norway, Denmark, Finland and
Sweden to try to obtain further documents. Unfortunately, English translations were
not available for some policies. Thus, the amount of information available varied
substantially between countries.


Policy review
Documents were reviewed by two independent observers (LI and IKC). Data on the
format and content of the policies, with particular attention to potential interventions
to be implemented, were extracted from the documents. Summaries were prepared of
the key policy features of policy: the assessment of the problem; the targets set; and
the strategic approaches taken to tackle mental health problems.


Policies on alcohol and drug abuse have not been included in this review. These
topics receive little attention within mental health policies, and when they are
mentioned this is usually in context of co-existing mental health problems.         The
exception is New Zealand‟s mental health policy which covers mental health and
addiction15. As alcohol and drugs are extensive topics in their own right, they have
not been covered in this report.




                                          15
16
    Section 2:

Overview of Mental
  Health Policy




        17
Documents on Mental Health Policy
Mental health is a priority for all countries and is currently undergoing major
development and investment by governments. Strategies on mental health can be
found in many documents across the countries studied.             The complete set of
documents used to inform this report is given in Appendix 1.             The following
paragraphs describe this variety of approaches using examples: they do not describe
all relevant policies in all countries.


Some countries have substantial sections on mental health issues within their overall
health policy or public health policy. For example, the US public health policy
Healthy People 2010 has one focus area on mental health16. Entitled Mental health
and mental disorders, the chapter is mainly about mental disorders with little on
mental wellbeing. Mental health is identified as one of nine priority areas in Japan‟s
public health policy17. The emphasis is on maintenance of mental wellbeing through
reducing stress and improving length and quality of sleep. Improving physical and
mental health and social wellbeing is the overall aim of Northern Ireland‟s public
health policy18   19
                       . Mental health also features in overall health policies of other
countries including Scotland20, New Zealand21 and England22.


Several countries have stand alone policies which deal with general mental health
issues. New Zealand15 and Australia23 have well developed policies which date from
the early 1990s. Scotland has an Action Plan which focuses on four key aims:
promoting mental health, reducing stigma, preventing suicide and promoting and
supporting recovery from mental illness24.           England has a National Service
Framework on Mental Health25, which covers health promotion, health care delivery,
suicide and carers. Finally, Wales has both an adult mental health strategy26 and a
strategy for children and young people27.


Many countries have topic specific policies although these vary between countries.
The most common topic is suicide prevention. Countries with suicide strategies
include England28, New Zealand29-31, Scotland32 and Australia33. Several countries
also have policies on mental health promotion including New Zealand34, Northern




                                             18
Ireland35 and Australia36. Only England37 and New Zealand38 have separate policy
documents on the prevention of stigma and discrimination.


We were unable to obtain many documents from the Scandinavian countries despite
contacting the Ministries of Health. Few of their documents are available in English.
For example although Finland has produced a report on public health approaches to
mental health in Europe39 and a review on the monitoring of mental health40, we only
found a policy document which dealt with quality recommendations for mental health
services41. Norway addresses mental health in its public health policy42 and describes
an Escalation Plan for Mental Health (1999-2006) which unfortunately is not
available in English (T Rogan, Norwegian Ministry of Health, personal
communication).      We were also unable to find policy documents for Canada.
However the current Pan-Canadian Healthy Living Strategy43 identifies mental health
as a topic for future development. Possibly in anticipation of this, Canada has recently
conducted a substantial review of mental health strategies both within Canada and in
four other countries44-46.


Supporting Documents
All countries have a range of supporting documents which have been produced in
conjunction with policy or have influenced policy development. Because of the
considerable number of such documents, they cannot be reviewed in detail. Thus, this
section presents only a few to illustrate the range of topics covered. For example, US
policy is supported by two Surgeon General reports, both of which were published in
1999: Mental Health: A Report of the Surgeon General47 and The Surgeon General’s
Call to Action to prevent Suicide48. New Zealand has companion documents for many
of its policy documents such as those for its health promotion49 and suicide50
strategies. Scotland has a briefing paper51 for its Action Plan and Australia has
background papers for its strategies on suicide52 53, depression54 and mental health
promotion/prevention55.




                                          19
Deinstitutionalisation of mental health services
The major reorganisation and deinstitutionalisation of the mental health services has
driven the development of public mental health policy in recent decades. The changes
in mental health services have occurred in conjunction with an updating of mental
health legislation in the majority of countries. Canada describes deinstitutionalisation
as a process involving three distinct phases which began in Canada in the 1960s and
continues to the present day44. The first involved a shift from care in psychiatric
institutions to care in psychiatric units in general hospitals.      The second phase
involved the expansion of mental health services in the community, while the third
and current phase focuses on integrating the mental health services across sectors in
order to enhance their effectiveness.


The move towards reducing the number of inpatients and closing many of the
traditional psychiatric hospitals has progressed at different rates between the countries
studied and also within countries56. The reduction in the number of in-patients in
mental hospitals began in the mid 1950s in the UK countries57, Australia58 and the
USA47. For example, within Australia and the USA the number of state psychiatric
beds were reduced from approximately 300 beds per 100,000 of the population in
1955 to around 40 per 100,000 by the early 1990s58. The Canadian Minister of
Health, in 1959, called for a greater emphasis on community mental health services59
which was followed by progressive deinstitutionalisation in the 1960s56. Sweden
began the process in the late 1960s60. Although Finland did not introduce these
changes until later61, over the 20 years from 1980 the number of inpatient beds fell
from 20,000 to 6,00062. Japan is currently embarking on a programme of reform, but
the government is aware that reform must occur at a pace that fits with the culture. It
is recognised that a substantial shift in attitudes towards people with mental illness
and the way in which they are managed will be required to complete the transition63.


The move from traditional psychiatric hospitals to community based services required
the integration of mental health services with a range of other services, particularly
primary care and social welfare services. The withdrawal of traditional psychiatric
hospital services created a need for more psychiatric beds in general hospitals as well
as substantially more community facilities. Mental health services were required to



                                           20
evolve rapidly to cope with the changes. Many countries found that keeping pace
with the developments was difficult and reviews conducted within the countries found
that services were not adequate62 64 65. One reason for the problems that ensued was
the withdrawal of inpatient beds from traditional psychiatric hospitals without
adequate alternative mental health care being provided60. The reforms have been
criticised in many countries, particularly around the problem of homeless and social
exclusion of those with severe mental illness66. The effects of deinstitutionalisation
still have a major impact on mental health policy and the concerns that are raised are
highlighted in many sections of this report.




                                           21
Mental health
Before reviewing policy on mental health it is important to clarify what is meant by
this term. The World Health Report 2001 from WHO11 points out that mental health
can be defined in many ways and may have different meanings in different cultures.
However it identifies the major components of mental health as including subjective
well-being, perceived self-efficacy, autonomy, competence, intergenerational
dependence, and self-actualisation of one‟s intellectual and emotional potential. It also
points out that there is general agreement that mental health is not simply the absence
of mental disorders. A more recent WHO report clarifies that good mental health is
fundamental to the wellbeing of individuals, families, communities and society as a
whole13.


The complex nature of mental health is reflected in policy. Most countries relate
mental health to well being. Scotland51 follows the Health Education Authority67 and
identifies three components of wellbeing: emotional, social and spiritual. Japan adds
intellectual health to this list17.    Northern Ireland68 construes wellbeing as three
different components: being:– how we feel in ourselves; belonging:– how we relate
to other individuals, the community and the culture; and becoming:– where our lives
are going. Building on Strengths34, New Zealand‟s mental health promotion strategy,
describes mental health as one of the four components of total well-being; the others
being physical health, spiritual health and environmental health. Australia identifies
the characteristics of good mental health as: happiness, competence, a sense of control
over one‟s life, high self-esteem and capacity to love, work and play69. Both Australia
and New Zealand report that this holistic approach to mental health concurs with the
concept of wellbeing held by the indigenous peoples of both countries23 34.


Some countries mention the influence of mental health on mental function. For
example Scotland51 and England70 state that it influences how we feel, think,
communicate and understand.           Northern Ireland68 comments on the influence of
mental health on our belief in our own and others‟ dignity and worth67. New Zealand
develops this to include equity and social justice34.




                                             22
Mental health is also described in terms of what good health enables individuals to do.
Several countries follow the WHO by mentioning: realising one‟s potential, working
productively and contributing to the community71. The USA adds to this the ability to
form fulfilling relationships16    47
                                        . Good mental health is recognised as essential in
ensuring our ability to cope with the normal life stress such as pain, disappointment
and sadness51 67 72. The ability to cope with these stresses also depends on emotional
and spiritual resilience68.




Mental ill-health
Mental ill-health covers a spectrum of conditions from mental health problems
through to clinically diagnosed mental illness. Thus it encompasses a broad range of
cognitive, emotional, and behavioural disorders that interfere with people‟s lives and
productivity23   73
                      . The WHO Report on mental health describes all the mental and
behavioural disorders in the ICD-10 classification (the International Classification of
diseases for mental disorders)11. The United States uses an alternative classification
system, DSM IV, but this covers broadly the same conditions47.


Mental ill health may occur at any stage during the life span and affect all socio-
economic groups, all cultures or ethnic groups and both males and females.
Commonly, mental illness is differentiated from mental health problems in policy
documents. WHO uses the terms mental and behavioural disorders for mental illness.
These are described as clinically significant conditions characterised by alterations in
thinking, mood or behaviour associated with personal distress and/or impaired
functioning11. Some countries, such as the United States16 and Australia 23 follow this
definition. Wales, however, in its adult mental health strategy, reserves the term
mental illness for the small proportion of people with the most severe mental
disorders26.


In addition to these diagnosable disorders all countries also discuss and address
mental health problems.          Australia and New Zealand follow the US Surgeon
General‟s definition of mental health problems as: diminished cognitive, emotional or



                                                23
social abilities that do not meet the criteria for mental disorders in severity or duration
of symptoms23 34 47. However, Friedli reports that the term “people with mental health
problems” covering the whole range of mental disorders, is more acceptable, as this
does not make a judgement about severity of the level of disability and does not rely
on an illness model51.


Most countries do not specifically address the diagnosable disorders in their mental
health policies. Policy tends to have a broad perspective on the areas covered. It is
concerned with the promotion of mental health; the prevention of mental disorders;
tackling stigma, discrimination and social inclusion among people with mental
disorders; ensuring the availability and quality of the services provided; and the
prevention of suicide. However these are treated in a general, rather than a disease
specific, way. The USA‟s Healthy People 201016 is unusual in that it deals almost
exclusively with the diagnosable mental illnesses.




                                            24
Scale of the problem
This section describes the scale of mental health problems in three sections. First it
covers WHO estimates of the global burden, then it reviews overall estimates from
individual countries and concludes with an assessment of the economic costs of
mental health problems.


Overall burden
Mental health problems account for a substantial proportion of the disease burden in
all countries. The WHO, in 2001, reported that around 450 million people worldwide
suffer from mental health disorders, and that mental and behavioural disorders
account for around 12% of the global burden of disease11. Within Europe, it is
estimated that one in four people will have a mental health problem at some time in
their lives74. More recently, WHO has reported that five of the ten leading causes of
disability worldwide are psychiatric conditions75. Further, it estimates that by 2020
neuropsychiatric conditions will account for 15% of disability worldwide, with
depression accounting for 5.7% of DALYs (disability adjusted life years)14.


National estimates
The Public Health Policy Healthy People 201016 reports that approximately 40
million Americans between the ages of 18 and 64 years, or 22% of the population,
will have a diagnosis of a mental disorder alone (19%) or a co-occurring mental and
addictive disorder in any given year16.        Norway reports that 15%-20% of the
population have some mental health problems64, similar to New Zealand which
reports that around 17% of the population suffer from mild to moderate mental
illness15. Northern Ireland estimates that, at any point in time, as many as one in six
of the population suffers from a diagnosed mental health problem such as depression
or anxiety35, while Australia‟s National Action Plan, reports that close to one in five
people are affected by a mental health problem within a twelve month period36.
England estimates that one in six of the general population has common mental health
problems at any one time and that over 900,000 adults claim sickness and disability
benefits because of mental health problems76. England also estimates that one in ten
new mothers will experience post natal depression and that one in 25 adults has a




                                          25
personality disorder76. Denmark describes mental disorders as one of the major
preventable causes of ill-health73.


Severe mental illness is estimated to affect between 2.5% and 3% of the population.
The USA reports rates of 2.6% and 2.8% among adults over 18 years during any
year16, while Norway and New Zealand estimate that 3% are severely affected by
mental illness15 64. England reports that one in 200 adults had a psychotic disorder in
the previous year and that one in 100 will experience schizophrenia at some time in
their lives76.


The prevalence of mental health problems appears to be increasing in some countries.
Sweden reports a considerable deterioration in the mental health of the population, as
measured by anxiety, unease, anguish, and sleep disturbance77. This is reflected in an
increase in the amount of sick leave for mental health disorders. The proportion of
people on long term sick leave with a diagnosis of mental health disorder increased
from 18% in 1999 to 25% in 2001. Canada reports that disability claims attributable
to mental illnesses are now higher than claims for cardiovascular disease and
estimates that disability insurance claims for mental health problems and mental
illnesses may rise to 50% of all claims administered through employer group health
plans in the next five years44. Finland also reports that the number of people claiming
a disability pension on grounds of mental health increased steeply during the 1980s
and 1990s78. This occurred mainly because of a growth in depression and other
neurotic disorders. However Finland also points out that there is limited data on the
prevalence and development of mental symptoms and disorders. In contrast to these
data, a report on social exclusion and mental health from England in June 200476
states that there had been no significant change in mental health problems in the
preceding decade, apart from a slight increase in neurotic disorders in men. However,
it also cites a 1995 textbook which states that many countries have seen sustained
increases in psychosocial disorders among young people since the 1940s.


The economic consequences of mental health problems
The level of morbidity and mortality from mental health problems has major
economic consequences both at individual and societal levels79.           People who
experience mental health problems and their carers often suffer severe financial


                                          26
hardship due to reduced productivity80. Country comparisons are difficult because
different methods of assessment are used81. There are some international reports
which provide estimates of cost but these are limited to a few countries and are often
several years out of date. For example a WHO report82 gives an estimate of $148
billion for the cost on mental disorders in the United States in 1990, and of £32 billion
for England in 1996. An estimate for Canada in 2002 was $14.1 billion. Within the
European Union, before the expansion in 2004, the cost of mental health problems
was estimated by the International Labour Office to be between 3% and 4% of the
GNP83. One country in that study, Finland, reported that in 1994 the direct costs of
schizophrenia were estimated to be higher than those from smoking83.


Only a few countries present estimates of the economic costs of mental health
disorders in public mental health policy documents. The USA, in its policy document
Healthy People 201016, echoes the WHO figure of $148 billion per year and
comments that a sizeable proportion is due to lost productivity due to work
disability16. England, in a report on social exclusion in 2004, estimates costs of over
£77 billion, caused by health care costs, the effect of premature mortality and missed
employment opportunities as well as the costs of social welfare76. It clarifies the
importance of missed employment opportunities (£23 billion), by pointing out that
only 24% of adults with long term mental health problems are in employment. It also
points out that people with mental health problems are at more than double the risk of
losing their jobs than those without.




                                           27
Causes of mental health problems
All countries that review the causes of poor mental health agree that the physical,
social and economic environments play a major role. However the way in which these
factors are conceptualised differs between countries and also between documents
from the same country. For example Denmark identifies genetic, social and
psychological factors as well as the quality of the working environment73. New
Zealand states that mental health disorders result from interactions between
physiological, psychological and social factors15. Australia emphasises the impact
that public policies can have on mental health. Policies on housing, welfare,
education, employment, justices and art, sport, recreation and the media 23 can help
create supportive social, economic, educational, cultural and physical environments.
A report from Canada develops the life circumstances and lifestyle approach by
identifying four groupings of factors that affect mental health. These are: lifestyle;
employment and work; social status, education and income; and stress and social
support. It then clarifies that lifestyle includes physical activity, nutrition, substance
use and self-care practices72. Lifestyle options are shaped by social and cultural
beliefs and relations, which in turn are influenced by economic, political and cultural
conditions and resources.


WHO categorises five sets of factors which influence mental health11. Although these
overlap with those from Canada they are phrased differently. These are
      socio-economic factors, particularly poverty, with its associated problems of
       low educational attainment, unemployment, deprivation and homelessness.
      demographic factors, such as gender and age;
      serious threats, such as conflicts or disasters;
      physical illness
      the family environment.


The documents from Northern Ireland take a slightly different approach. In its
consultation document on mental health promotion, Northern Ireland distinguishes
between factors which promote mental wellbeing and those which detract from it68.
Promoting factors include self esteem, environmental quality, self management skills
and social participation, whereas detractors include emotional abuse, stress and social


                                            28
alienation. It points out that these can operate at macro (regional), meso (family and
community) and micro (individual) levels. Northern Ireland develops these ideas in
its Action Plan35 where it characterises the determinants of mental ill-health as
internal and external factors. The internal factors include poor quality relationships,
feelings of isolation, disharmony, conflict or alienation, and physical illness or
disability. External factors include poverty and unemployment, social exclusion and
discrimination, poor quality physical environment, negative peer pressure, abuse or
violence and family or community conflict.


England, in its White Paper Our Healthier Nation70, also identifies internal and
external factors, although it does not refer them as such. The three internal factors are
social isolation, genetic predisposition and peri-natal factors. The external factors
include poverty, poor education, major life events, drug and alcohol misuse and poor
parenting.   The English NHS elibrary for mental health adds to the factors,
specifically mentioning racism and homophobia among other forms of discrimination
which adversely affects mental health84.



Groups at risk
Many countries recognise that some groups are at high risk of mental health problems.
Children and young people are frequently mentioned by countries such as Denmark73
and Northern Ireland18. Norway places special emphasis on the prevention of mental
health problems of children42 and has developed a policy on this (document not
available in English). Scotland conducted an assessment of the mental health needs of
children and adolescents85, on which was based a policy for promotion, prevention
and care (currently at the consultation stage)86. In England one standard of the
National Service Framework for Children, Young People and Maternity Services87 is
on mental health and a strategy, Mental Health and Psychological Well-being of
Children and Young People, is also at the consultation stage88.


Older people are also recognised as being at risk of mental health problems. New
Zealand points out that the prevalence of mental illness is high among older people,
particularly for depression and anxiety disorders15. Northern Ireland makes the
improvement of the mental health of older people one of the key objectives of its


                                           29
overall health strategy18. Australia mentions that older people in residential care tend
to have more depressive symptoms89. Finally England has a National Service
Framework for older people which sets a standard for the promotion of their mental
health and the treatment of the mental health problems, particularly dementia and
depression90.


Those who care for people with health problems are also more likely to suffer from
mental health problems. Caring for individuals who have serious and chronic illness
can be demanding and stressful. Several countries, including Australia23, New
Zealand15, England91and Wales26, identify this risk and have specific strategies to
reduce it.


Social disadvantage and deprivation are recognised to increase the risk of mental
health problems. Denmark points out that those with little education have the most
impaired mental health73, and England emphasises the high risk among those who left
school aged 15 years or under76. It also refers to the increased prevalence of problems
among the unemployed, lone parents as well as deprived and abused children 76        92
                                                                                          .
England adds that refugees are at risk because they often suffer from poverty,
isolation and low social status84. Australia is unique in having an entire policy
document devoted to a mental health action plan for all culturally and linguistically
diverse groups93.


Several countries are concerned about the mental health of prisoners although
England and Wales, in a joint document, are the only countries to have a stand alone
policy for prisoners‟ mental health. In December 2001 the English Department of
Health, the National Assembly for Wales and HM Prisons published a strategy to
develop and modernise mental health services within prisons94. This pointed out that
up to 90% of prisoners have a diagnosable mental illness, substance abuse problem or
both. Further, it points out that among young offenders and juveniles this figure can
reach 95%. The document also noted that the prison mental health services was not
keeping pace with developments within the NHS and therefore not delivering the
National Standard for Mental Health effectively within the prison setting.         It is
estimated that around 50% of the Prison Service health care budget is spent on mental
health services, but the report concluded that it may not be being used as effectively


                                          30
as it might. Many high level changes were therefore proposed to improve services
including: developing mental health promotion services to meet the needs of
prisoners; providing access to primary and secondary care; and providing access to
effective treatments and suicide prevention programmes. A few months later a health
promoting prisons strategy was produced by the Prison Policy Unit (PHPU) and the
Prison Health Task Force (PHTF), joint units of the Prison Service, and Department
of Health95.




                                        31
Human rights
People suffering from mental health disorders are at increased risk of having their
human rights violated96. Historically, people with mental illness were admitted to
psychiatric hospital and often held against their will. The concern was to protect
members of the public from harm from dangerous patients. Much of the early
legislation on mental health was directed towards protecting the public rather than
safeguarding the rights of people with mental illness97. Under that system people with
mental health problems were likely to encounter violations of their human rights such
discrimination, unemployment, social exclusion as well as compulsory detention and
treatment. Current concerns with human rights date from the Universal Declaration
of Human Rights which was adopted by the United Nations in 194898. Although there
is no specific comment on people with mental disorders, they are covered implicitly in
the section on people with disabilities.


The 2003 WHO document Mental Health Legislation and Human Rights97
recommends that human rights should be an integral part of the design,
implementation, evaluation and monitoring of mental health policies and
programmes. It states that these should include the rights to: equality and non-
discrimination; dignity and respect; privacy and individual autonomy; and
information and participation. This is reinforced in the new WHO Declaration on
Mental Health99 which requests that countries enforce policies and legislation that set
standards for mental health activities and upholds human rights. WHO also draws
attention to the important role of mental health advocacy in promoting the human
rights of people with mental health problems100.        It reports that the advocacy
movement has substantially influenced mental health policy and legislation in several
countries.


Some countries emphasise the need for their policy and programmes to comply with
human rights legislation. For example, Northern Ireland‟s health promotion strategy
explains that the Department of Health, Social Services and Public Safety will ensure
the policy‟s compatibility with the Human Rights Act and the European Convention
on Human Rights35. New Zealand‟s National Plan to counter discrimination and




                                           32
stigma incorporates a human rights model together with the social model of disability
as the basis of their action plan38.


Australia is particularly concerned about the rights of people suffering from mental
disorders. The Australian Government has published Mental Health statements of
rights and responsibilities69 which offers guidance to consumers and providers of
mental health services. First published in 1991, it has been updated and reprinted four
times. The document stresses that people with mental health problems should be
protected from abuse and neglect at all times. It clearly lays out the rights and
responsibilities of consumers, carers, families and providers of mental health services
in activities for the prevention of mental disorders, in access to treatment, during
admission to hospital or to a treatment programme and through rehabilitation.
Australia‟s most recent mental health policy notes that concern for the human rights
of people with mental disorders is shifting from abuse of those with mental health
problems to an awareness of neglect23. It argues that this can occur either because of
unidentified need or through inadequate provision of care.




                                          33
Principles
Mental health policy is unusual in that most countries outline the principles on which
such policy is based. This may be a consequence of concerns about human rights,
although this is not stated explicitly in policy. The way the principles are cast differs
between countries and between policy documents. For example Northern Ireland‟s
current strategy and action plan for promoting mental health specifies its principles as:
a holistic approach; empowerment of individuals; and respect for personal dignity35.
Wales identifies four principles in its strategy on adult mental health services: equity
of access and standards of care; empowerment of users and carers; effectiveness of
services; and the efficient use of resources26. However in its strategy on children27,
Wales expands this to eight principles. These cover similar topics but introduce
specific children‟s issues, such as parenting, adherence to legal requirements and the
need for accountability. Australia‟s current National Mental Health Action Plan23
specifies eleven principles which emphasise the rights of consumers their families and
carers, the need for timely, high quality responsive services which are oriented to
recovery. However they also refer to the need for investment in the workforce,
sustainability and innovation, and the need to integrate mental health with the broader
health sector and across the whole of government. New Zealand has had a statement
of principles since 1994101. The 14 topics cover similar issues of empowerment, and
the delivery of appropriate high quality cost-effective services. However New
Zealand‟s principles also emphasise personal dignity, the rights of people with mental
health problems and the need for services to enable consumers to participate fully in
society. Scotland‟s recent consultation document on children and young people‟s
mental health86 also includes confidentiality and inequalities in health as principles.




                                           34
Goals and Targets
Many countries set broad goals for mental health in their overall health policy
documents. These are largely similar, aiming to reduce the prevalence and the impact
of mental health problems and to improve mental health services. Norway aims to
prevent mental health problems, but places special emphasis on children42. Denmark‟s
goal is that the prevalence of mental disorders should be reduced73, but also draws
attention to the care of children who have a parent who has a mental health problem.
New Zealand intends to improve mental health by tackling stress, depression, suicide,
severe mental illness and dementia21. Ireland‟s 2001 Health Strategy102 aim is more
developmental: that a new action programme for mental health will be produced.
Scotland identifies mental health as a leading priority for the NHS in Scotland in the
1999 Public Health White Paper20. The USA has the comprehensive goal of ensuring
access to appropriate and high quality services16. Northern Ireland‟s most recent
health policy highlights the importance of mental health by including it in the
overarching goal of health policy: to improve the physical and mental health and
social wellbeing of the people of Northern Ireland18.


More specific goals are set in mental health policy documents, which can expand on
or complement those in the overall health policies. Norway has set the goal for its
National Programme for Mental Health of a major expansion and reorganisation of
mental health services64. Its public health strategy describes plans for A Strategy for
Children’s and Young People’s Mental Health42, in which the target is to ensure that
children and young people who develop mental health problems are given local and
personal treatment as soon as possible. New Zealand sets two such goals: to decrease
the prevalence of mental health problems; and to reduce the impact of mental
disorders on consumers, their families, caregivers and the community15. Scotland‟s
policy has four aims: to increase awareness of mental health; to eliminate stigma; to
prevent suicide and to support recovery24. Australia also has four broad aims: to
promote the mental health of the Australian community; to prevent the development
of mental disorders, where possible; to reduce the impact of mental disorders; and to
assure the rights of people with mental disorders23.




                                          35
Targets
Mental health is one of the 21 targets set in the WHO‟s European Region‟s Health for
All in the 21st century (Health 21)103. The overall target is that by 2020 people‟s
psychosocial wellbeing should be improved and better comprehensive services should
be available to, and accessible by, people with mental health problems. In particular,
Health 21 wants the prevalence and adverse health impact of mental health problems
to be substantially reduced, while people‟s ability to cope with stress is increased. It
also seeks to reduce suicide rates by at least one third.


The use of targets varies for mental health varies across the countries studied. Some
countries do not have numerical targets, while for those that do, the topics on which
the targets are set varies between countries. The most common topic for target setting
is in suicide. England, Japan, Scotland, the USA and Wales all have targets on
suicide. These are described in detail in the section on suicide prevention.


The USA has the greatest number of targets for mental health. These fall into three
categories: mental health status improvement; treatment expansion; and state
activities. Mental health status improvement targets include: reducing the proportion
of homeless adults who have serious mental illness from 25% to 19%; increasing the
proportion of persons with serious mental illness who are employed from 43% to
51%; reducing the relapse rates for people with eating disorders; as well as two targets
on suicide. The treatment expansion targets focus on increasing the numbers of adults
and children who are screened and receive appropriate treatment for mental health
problems. There are also targets to increase treatment for people with co-occurring
substance misuse and mental health problems and for prisoners with serious mental
problems. Targets to monitor state activities aim to ensure that services are in place
and that states track consumer satisfaction with the services16. Several of these targets
are new to Healthy People and therefore did not have baseline data or numerical
targets at the time of publication.


Northern Ireland and Wales set targets to improve the mental health status of the
population as measured by health questionnaires. Northern Ireland has set targets to
reduce the proportion of people with a potential psychiatric disorder (as measured by
the General Health Questionnaire (GHQ 12) score) in the population as a whole and


                                            36
for several groups. The target for the whole population is to reduce the GHQ 12 score
to 19.5% by 2008 from 21% in 200135. Wales uses a different questionnaire, and
wants to increase the Mental Component Score (MCS) for Wales to 50 by 2012. The
MCS for Wales has remained constant at 49.5 since 1995104. Wales and Northern
Ireland are the only countries to have targets for the mental health of carers. The
target for health inequalities in mental health in Wales is to increase the mean MCS
score for carers by one point by 2012104. Northern Ireland wants to improve the
mental health and wellbeing of carers by a quarter between 2001 and 2025 as
measured the General Health Questionnaire (GHQ 12)18.


Japan‟s mental health targets are unique17. Baseline data for Japan‟s targets are
obtained from the 1996 Awareness Survey on Health. The first target is to reduce the
percentage of people who have experienced stress over the past month by 10%. The
second target is on sleep and is in two parts. The first part is to reduce the percentage
of “people who cannot recover from fatigue and rest through sleep” by more than
10% from a baseline value 21% in 1996. The second part is to reduce the number of
“people who use sleep aids (sleeping pills and tranquilisers) or alcohol to induce
sleep” by more than 10% from 14.1% in 1996. Japan‟s third target is on suicide.




                                           37
Development of Public Mental Health Policy:
Case studies from Australia and New Zealand
Australia and New Zealand have the longest standing public mental health policy of
all the countries studied. Consequently their policies are the most well developed.
The origins of both countries policies can be traced to the 1980s when a series of
national reviews highlighted a need for a substantial increase in both the quantity and
quality of mental health services. Much of the work that ensued to develop the
services, has been charted in policy documents, mental health reports, evaluations of
policy and background papers. Although many of these are discussed throughout this
report, this section gives an indication of some of the landmark events and policies
which have driven the development of policy in both countries. They provide an
admirable model for the creation and development of policy.


Australia
1984     Reports by the Royal Australian and New Zealand College of Psychiatrists
         advocated the need for a national mental health policy.
1988     A Department of Health commissioned report made recommendations for
         policy and service reform, having identified funding and the organisation of
         mental health services as areas of concern.
1989     A national working party was established to advise state and federal
         ministers on possible action and policy developments at national level.
1990     Health Ministers agreed to the development of a national mental health
         policy.
1991     The Mental Health Statement of Rights and Responsibilities69 was adopted
         by Australian Health Ministers.       This statement aims to ensure that
         consumers, carers, advocates, service providers and the community are
         aware of their rights and responsibilities and can be confident in exercising
         them.
1992     Australia‟s first National Mental Health Policy105 was endorsed by all states,
         territories and the federal government. It defined the broad aims and policy
         directions to guide the reform process in twelve priority reform areas.




                                          38
       The first National Mental Health Plan was also produced in 1992. Together,
       the two documents were known as the National Mental Health Strategy. The
       Plan charted an action plan for the first five years of the Strategy and
       described how the National Mental Health Strategy would be implemented
       at Commonwealth and State/Territory level.
1997   The Evaluation of the Mental Health Strategy Final Report106 was
       published. The report confirmed that prior to the introduction of the Mental
       Health Strategy, the mental health system in Australia had been inadequate.
       Although considerable gains had been made since 1992, it also reported
       dissatisfaction with many aspects of mental health services, particularly
       among consumers and carers, primary care practitioners and the community.
       Stigma and discrimination against those affected by mental illness was
       identified as a major problem.        The report concluded that much work
       remained to implement the National Mental Health Policy.
1998   The Second National Mental Health Plan107 was developed and endorsed by
       Health Ministers. It built on the achievements of the first Plan and identified
       three new areas for national activity for the period 1998-2003: promotion
       and prevention; development of partnerships in service reform; and quality
       and effectiveness of service delivery. The emphasis on common mental
       health problems, such as depression was also increased.
1998   A National Health Priority Areas Report Mental Health. A report focusing
       on depression54 was published.        The report describes mental health in
       general, and depression in particular within Australia.       It discusses the
       prevention and management of depression, including different treatments for
       different groups.   It gives examples of current Australian initiatives to
       address depression and discusses opportunities and future directions that
       may be taken forward in a National Depression Action Plan.
2000   Several new policy documents were produced in response to the identified
       need for further action:
       The National Action Plan for Promotion, Prevention and Early
       Intervention36 for Mental Health and its companion document Promotion,
       Prevention and Early Intervention for Mental Health - A Monograph55. The
       Action Plan provided a framework for a coordinated national approach to the
       promotion of mental health and prevention and early intervention for mental


                                        39
        health problems and mental disorders.          The Monograph provided the
        theoretical and conceptual framework and background for Action Plan.
        The suicide strategy, Living is for Everyone (LIFE) which is comprised of
        three documents33    52 53
                                     was introduced. The Framework aims to foster
        strategic partnerships and to position suicide prevention effort across all
        sectors.
        The National Action Plan for Depression89 was also launched. It provided a
        strategic framework for activity to address depression.           It covers
        interventions including the promotion of mental health literacy, prevention
        and early intervention in depression, assessment and treatment of depressive
        disorders and identification of research priorities.

Evaluation of the Second Plan had several parts: a mid-term international
commentary; a series of national community consultations; the National Mental
Health Report 2002; and a review of mental health in the Australian Health Care
Agreements undertaken by the Improving Mental Health Reference Group.


2001    The International Mid-Term Review of the Second National Mental Health
        Plan for Australia108 was conducted by a psychiatrist from the UK, and a
        mental health nurse and lawyer from the USA. It provided an international
        perspective on the Strategy outlining major achievements, identifying
        problems and suggesting ways forward.
2003    The Evaluation of the Second National Mental Health Plan 1998-2003109
        reported on the four parts of the evaluation. The main findings were that the
        capacity to respond to the needs of people with mental illness had increased
        through the mainstreaming of inpatient care and increasing community care.
        The role of Primary Care had increased substantially and the mental health
        agenda had broadened away from a focus on the treatment of the severely ill
        to incorporate mental health promotion, prevention of mental illness, early
        detection, and treatment and rehabilitation and recovery. However, it was
        also recognised that much more was required, and thus supported the
        development of a new Plan.
2003    In July 2003, the National Mental Health Plan 2003-200823 was officially
        endorsed by Australian Health Ministers to ensure the continuation of the


                                          40
         National Mental Health Strategy for a further five years. Key themes taken
         forward in this Plan are: promoting mental health and preventing mental
         health problems and mental illness; increasing service responsiveness;
         improving quality; and fostering research, innovation and sustainability.
2004     The National Framework for Implementation of the National Mental Health
         Plan 2003-2008 in Multicultural Australia93 was introduced. It is designed
         to complement and expand on existing mainstream mental health policy,
         especially the National Mental Health Plan 2003-2008. Its main purpose is
         to help ensure the right of all Australians to good mental health, equal access
         to quality mental health services and an opportunity to participate in their
         health care.


In addition to the documents mentioned, many other reports were produced. For
example the National Mental Health Reports which have been published since the
commencement of the Mental Health Strategy, annually to 1997, then biannually from
2000, have had a role in directing policy. Together these documents provide a clear
picture of the evolution of policy through repeated rigorous evaluation.




New Zealand
1988     The first Mason Report on Forensic Psychiatric Services and several
         subsequent reports revealed major concerns about mental health services in
         New Zealand. These included:

              the low level of resources currently available to community mental
               health services
              a lack of provider responsiveness to the needs of consumers, caregivers
               and their families
              poor delivery of appropriate services to Maori
              a lack of resources for services targeted at children and their families
              disproportionate demands upon mental health services from groups
               such as youth, Maori, and those in the criminal justice system
              poor coordination between community based and hospital based
               mental health services




                                           41
           uneven resource allocation between the competing needs of
            community and institutional services as the process of
            deinstitutionalisation has continued
           difficulties in the recruitment of mental health staff, particularly Maori
            staff and clinical specialists
           the lack of a systematic database that would show who uses the mental
            health services, and a lack of detailed information about who would
            potentially use the mental health services
           unclear lines of accountability between the various agencies which
            deliver mental health services.

       Following this, the New Zealand Government determined to reform the
       services and introduced a new set of strategic directions to ensure that a
       coordinated and integrated strategy was in place.


1994   Looking Forward – Strategic Directions for the Mental Health Services101
       was New Zealand‟s first national mental health policy. The strategy was
       based around two key goals: to decrease the prevalence of mental health
       problems in the community; and to improve the health status of, and reduce
       the impact of mental health disorders on consumers, families, carers and the
       community. These goals have remained constant since 1994. Actions were
       focused on prevention; early intervention and treatment; and reducing
       stigma, stereotyping and prejudice against people with existing mental
       illness. It also pledged to develop specific services to meet the needs of
       Maori
1996   A review by the Mental Health Strategy Group reported that substantial
       financial investment had been made and many new services had been
       introduced, but progress towards the goals of Looking Forward needed to be
       more measurable.
1996   Another Mason Report supported the findings of the Mental Health Strategy
       Group.    It concluded that, despite substantial investment, funding and
       services were insufficient to meet the needs of those most severely affected
       by mental illness. It made several recommendations including the need for a
       public awareness campaign to reduce stigma and discrimination.
1996   The Mental Health Commission was established in response to
       recommendations of the 1996 Mason Report. Initially it was given a five


                                       42
       year term, but this has subsequently been extended twice, currently to 2007.
       The Commission is responsible for ensuring the implementation of the
       mental health strategy by monitoring and reporting on the performance of
       key agencies, working with stakeholders to promote a better public
       understanding of mental illness and reduce discrimination, and working to
       promote recruitment and appropriate training of personnel
1997   Moving Forward – The National Mental Health Plan for More and Better
       Services65, the implementation plan for Looking Forward101 was published.
       It built on the five strategic directions contained in Looking Forward and
       aimed to address mental health promotion, prevention and primary care
       activities in addition to the established mental health services.     It set
       numerous objectives and targets although the majority were at government
       level around policy development, putting services into place and fiscal
       matters.
1997   The Like Minds, Like Mine project, to counter stigma and reduce
       discrimination associated with people with mental illness was launched in
       response to a recommendation from the Mason Report of 1996.             The
       Committee recommended that the government should fund a public
       education campaign which it believed would reduce discrimination. Initially
       this was a five year project. Since 2001 the Government has maintained the
       funding through public health baseline funding.
1998   The Blueprint for Mental Health Services in New Zealand. How Things
       Need To Be110, in which the Mental Health Commission set out its view of
       the qualitative and quantitative changes that were required to fully
       implement the National Mental Health Strategy.        It provided practical
       support to help planners, funders and providers of mental health services to
       implement more and better mental health services. Endorsed and supported
       by successive Ministers of Health, it has been adopted as a national policy
       and planning document. It describes the broad groupings of people who
       need mental health services and the range of services that need to be
       available to meet the needs of these people.
1998   Two youth suicide prevention strategies29 30 and a review of the evidence on
       the prevention of suicide among young people50 were produced.           The



                                        43
       strategies focus on a range of cross government actions to reduce suicide
       among young people.
1998   Another policy on the mental health of young people, New Futures. A
       strategic framework for specialist mental health services for children and
       young people in New Zealand111 was introduced. It addressed the needs of
       children and young people with mental health problems, focusing on those
       with the most severe problems. It provides a framework for the way in
       which effective and treatment can delivered to this group.
2001   The Mental Health Commission Strategic Plan 2001 – 2004 Building on the
       Blueprint112 outlines goals and actions that the Commission will take to
       continue to ensure the strategy is implemented.
2001   Toolkits for District Health Boards were introduced to ensure that the 13
       priorities of the New Zealand Health Strategy were addressed. Three were
       relevant to the mental health agenda: Mental Health113; Suicide Prevention31
       and Minimising Alcohol and Other Drug Related Harm114
2001   Building on Strengths: A Springboard for Action115, a consultation document
       on promoting mental health and a companion document Building on
       Strengths: A Guide for Action were published49
2002   Building on Strengths34, the health promotion strategy was published. An
       action plan for its implementation is due in July 2005.
2002   The results of an independent review of the impacts of the national media
       campaign to counter stigma and discrimination associated with mental
       illness were reported116. It revealed that recall of the campaign was high and
       that attitudes were changing. It also reported an increasing awareness that
       depression is a form of mental illness. However, there was a minimal effect
       in increasing the acceptance of people with a diagnosis of schizophrenia.
       These findings raised concerns that the campaign might be fostering a
       concept of acceptable and non-acceptable mental illness116.
2003   A draft plan, Like Minds, Like Mine. National Plan 2003-200538 to reduce
       stigma and discrimination was published. The Plan draws on evaluations
       over the three preceding years.       The evaluations clarified that public
       awareness of mental health problems had increased and that quantifiable
       changes in attitudes had been observed. However, people with mental health



                                        44
         problems were still experiencing discrimination. Thus the current strategy
         focuses on reducing discrimination.
2004     A draft of a new strategy Improving Mental Health Second National Mental
         Health and Addiction Plan 2005-201515 was published. It proposes a series
         of actions for the next five to seven years.      It clarifies the vision and
         direction of mental health services over this period and proposes actions that
         need to be taken. The focus is on the building a more comprehensive system
         over time, by integrating and coordinating early access to effective primary
         care with an improved range and quality of specialist mental health services
         that are community-based. .
2005     The consultation document New Zealand Suicide Prevention Strategy A Life
         Worth Living117 was developed in response increasing problem of suicide in
         New Zealand. Previous suicide prevention strategies focused on young
         people, but it was recognised that a broader response to the problem was
         required. Thus a draft strategy addressing suicide prevention for all ages
         was developed. It builds on the youth strategies but extends the goals and
         objectives to include all age groups.


Like Australia, New Zealand has many more reports and documents that have been
influential in the development of public mental health policy. Those discussed above
give some insight into the effort involved in providing a coherent overall strategy.
These approaches to policy development are not just to be commended but to be
recommended as the model for other countries.




                                          45
Mental Health Declaration and Action Plan for Europe
WHO has recently produced a Mental Health Declaration99 and Action Plan118 on
mental health. Both were signed by the Ministers of Health of the Member States of
the European Region of the World Health Organisation in Helsinki in January 2005.
The Ministers endorsed the statement that there is no health without mental health,
and that mental health is central to the human, social and economic capital of nations.
They recognised the need for comprehensive evidence based mental health policies in
order to achieve mental well-being and social inclusion of people with mental health
problems. The Declaration and Action Plan provide guidance on how this may be
achieved. Individual countries also committed to reporting back to WHO on the
progress towards implementation of the Declaration.


The Mental Health Declaration
The Mental Health Declaration acknowledges the transformation within mental
health services in Europe and welcomes the shift to a wide range of community based
activities. It recommends that the scope of policy and practice on mental health
should cover five broad areas: promotion of mental health; tackling stigma,
discrimination and social exclusion; prevention of mental health problems; care for
people with mental health problems and their carers including involvement in
planning and delivery of services; and recovery and inclusion into society of those
who have experienced serious mental health problems


Mental Health Action Plan
The Action Plan takes forward the priorities identified in the Declaration by
proposing ways in which comprehensive mental health policies can be developed and
implemented in the countries of the WHO European Region.             The Action Plan
describes twelve areas requiring action. These include: establishing mental health as
a vital part of public health policy; improving the provision of services; establishing
effective information systems; ensuring adequate funding; the promotion of mental
wellbeing; reducing stigma and discrimination; and preventing mental ill health and
suicide.   It also discusses the challenges in addressing each area and describes
activities which may be considered for development and implementation. The Action
Plan provides a template for the development of public mental health policy.



                                          46
  Section 3:

  Strategic
Approaches to
Mental Health
  Problems




      47
Overview
Countries organise their strategic approaches in differing and sometimes overlapping
ways. Details of strategic approaches can be found in overall health policies, in
general public health policies, mental health policies or in policies tackling specific
issues such as mental health promotion, suicide, stigma and discrimination, and health
service provision.


Producing a synthesis of strategic approaches to tackling mental health with its huge
diversity across countries is a complex task. To simplify it, the information on
interventions will be presented in ten sections, even although individual countries may
not have their policies structured in this way. Most countries recognise that a
coordinated approach is necessary to tackle mental health.


The ten sections are:
 1     Development of mental health policy and strategy
 2     Mental health promotion covering approaches to improve mental health and
       wellbeing and prevent mental health problems
 3     The wider determinants of mental health
 4     Provision of services for identification, treatment and rehabilitation of people
       with mental health problems
 5     Specific groups
         Children and young people
         Older people
         Carers
 6     Non-governmental organisations
 7     Stigma
 8     Suicide
 9     Attempted suicide and deliberate self harm
10     Depression




                                          48
Development of mental health policy and strategy
Many countries include policy development as a strategic area for action. Thus
Northern Ireland includes policy development as one of the four strands of the Action
Plan in its health promotion strategy35. Australia is proposing to increase the extent to
which mental health promotion is incorporated into policy at the national, regional
and local levels23.    The Welsh policy on adult mental health proposes that the
National Assembly will review the evidence on the causes of stigma to identify the
means to combat it26. The National Assembly will also coordinate the development of
an education strategy to inform the public about mental illness and the services
available for treatment. Norway adopted a national programme for a major expansion
and reorganisation of the mental health services with major increases in funding for
the period 1999-200664. New Zealand is careful to state dates for the completion of
policy development. For example its Mental Health and Addiction Plan 2005-2015
states that by July 2008 the Ministry of Health and district health boards will have
revised the mental health service specifications of the nationwide service
framework15.


Considerable attention is also given to the need to develop intersectoral working
across a range of groups. Scotland provides a comprehensive list that includes
government departments, health care services, social welfare, employment agencies,
local authorities, employers and trade unions, national and local voluntary
organisations, the police, the prison service and local community leaders24. Northern
Ireland also advocates partnerships to ensure that the mental health needs of groups in
specific settings are addressed35. These include older people, children and young
people, in schools, the workplace, within rural support networks and prisons.
Northern Ireland plans to form an implementation group that will oversee the
implementation of the strategy and be responsible for regular reporting to a ministerial
group.    New Zealand plans to create safe and supportive environments through
partnership with a variety of sectors including cities, communities, workplaces,
schools and homes34.




                                           49
Mental Health Promotion
Mental health promotion features prominently in all countries‟ policies.         It is
increasingly becoming the major thrust of mental health policy. The definition of
mental health promotion varies across countries but broadly addresses the same
issues: improving mental wellbeing; reducing the incidence and the impact of mental
health disorders; assisting in the recovery from mental illness; and improving the
quality of life of those with continuing mental health problems. Thus the benefits of
mental health promotion are recognised to go beyond the prevention of mental illness
to include social, economic and general health benefits84.


New Zealand bases its policies15 34 on the statement from Joubert and Raeburn: that
mental health promotion uses strategies that foster supportive environments and an
individual‟s resilience, while showing respect for culture, equity, social justice and
personal dignity119. New Zealand also notes that mental health promotion should
enhance the capacity of individuals and communities to take control over their lives
and improve their mental health34. Australia states that mental health promotion aims
to protect, support and sustain the emotional and social wellbeing of the population
from the earliest years, through adult life to old age23.     A report from Finland
recommends that mental health promotion at the individual level should focus on
personal autonomy, adaptability, and ability to cope with stressors, self-confidence,
social skills, social responsibility, and tolerance120.


A key element of mental health promotion is identifying the groups within society at
whom the strategies should be targeted. Australia takes a very systematic approach to
identify groups, basing its current strategy on the population health framework23.
This approach takes into account the complex interaction of biological, psychological,
social, environmental and economic factors and addresses need across the whole
lifespan from infancy to old age and among different population groups. England
says that mental health promotion involves any action to enhance the mental
wellbeing of individuals, families, organisations or communities84. A report from
Scotland suggests that it is concerned with sectors of society (individuals, families,
organisations, communities), the factors which influence how these groups think and
feel, and the impact this has on overall health and wellbeing51. Northern Ireland



                                             50
develops this by emphasising the needs of high risk groups and people with mental
health problems, their families and carers35. WHO adds further population groups
including students, low income communities and people from immigrant or minority
groups13.


Interventions
The scope for health promotion is vast. A common approach is to identify different
levels of action for interventions.    Scotland51, England121and Northern Ireland35
follow three levels suggested by WHO13:
i      Strengthen individuals or increase mental resilience by promoting self esteem,
       life and coping skills.      Areas for action include improving skills in
       communicating, negotiating, relationships and parenting.
ii     Strengthening communities, which involves increasing social inclusion and
       participation, improving local environments, developing health and social
       services which support mental health, anti-bullying strategies in schools,
       workplace health, community safety, childcare and self-help networks to
       reduce structural barriers to mental health.
iii    Reducing structural barriers to good mental health through initiatives to reduce
       discrimination and inequalities and promoting access to education,
       employment, housing and support for vulnerable groups.


New Zealand‟s mental health promotion strategy is accompanied by a Guide to
Action49 which reviews the evidence of effectiveness of mental health promotion
interventions cited in the scientific literature, often in systematic reviews. Examples
of effective interventions include: support visits for new parents can improve mental
health in children and adults living in disadvantaged communities; supported
employment in normal working environments for those recovering from mental
illness is effective in keeping people in employment; coping skills and support to
newly separated people can improve mental health over the long term; and regular
exercise has been shown to decrease mental illness while aerobic exercise is
associated with a decrease in anxiety. New Zealand is currently developing an action
plan on mental health promotion, which is due to be launched in July 2005.




                                          51
Australia‟s policy on mental health promotion is the most detailed36. The Action Plan
identifies 15 separate groups for attention. These include seven groups across the
lifespan, whole communities, those experiencing adverse life events, remote and rural
communities, indigenous people and people from diverse cultural and linguistic
backgrounds, consumers and carers, the media and health professionals and clinicians.
Thus for each of the 15 groups the Plan systematically outlines a course of action.
Initially the outcomes are listed. This is followed by the rationale for the proposed
plan. The evidence of effectiveness of interventions for the group is then briefly
reviewed and potential research questions are posed. Finally, brief details of the
proposed interventions are given. This is supported by information on who will be
involved in delivering the agenda, where the interventions will take place, how the
interventions are linked to other national initiatives and a list of the process and
outcome indicators that will be used to monitor progress.


To illustrate the nature and range of interventions in the Australian policy, examples
of proposed interventions for some of the groups are listed below.
For the perinatal period and infants 0-2 years
  Provide home visiting and parent support programs for those families at risk of
    mental health problems
  Provide workplace support for parents through family friendly workplace policies
    and practice
  Develop and evaluate programs that deliver quality infant childcare promoting
    social and emotional wellbeing, particularly for infants at high risk of mental
    health problems
For individuals, families and communities experiencing adverse life events
  Develop, implement and evaluate programs to prevent violence and abuse and
    their adverse effect on mental health
  Develop, implement and evaluate projects to reduce the risks associated with
    unemployment
  Develop, implement and evaluate projects to reduce the mental health burden of
    disability and chronic illness, focusing on reducing stigma and supporting carers
  Develop and pilot a comprehensive, evidence-based, prevention program to
    reduce the risks associated with family breakdown for children and families



                                            52
Settings and Stakeholders
Interventions on mental health promotion involve a wide range of stakeholders in a
variety of settings. Australia provides the most systematic review of this36, although
the interventions proposed by other countries also include many stakeholders. The
advantage of the Australian approach is that it specifies the stakeholders and their
involvement. Australia identifies key sectors involved, such as childcare, education,
housing, employment or community. Within each of these sectors a list of key
settings are identified.     For example within the welfare sector potential settings
include child protection services, counselling services, and employment services.
Finally, the individuals and groups involved, both consumers and service providers
are identified. Those charged with implementing the interventions include teachers,
health care professionals at many levels, clergy, police, youth workers and volunteers.
Australia also points out that identifying the key strategic sectors, settings and people
that contribute to delivering the interventions at an early stage is crucial in planning
and developing services55.


The media are often highlighted as an important group. The media plays a crucial
role in mental health promotion by conveying information and influencing community
attitudes and perceptions of social norms36. Australia points out that media coverage
often reflects the widespread misunderstandings of mental health problems and
mental disorders. Thus it proposes to engage the media to promote mental health
through an educational programme.         Within the   USA a foundation, the Carter
Fellowships for Mental Health Journalism, was established in 1996122.                The
fellowships supply funding for journalists in the USA, New Zealand and South Africa
to learn more about mental health issues and to increase the number of high quality
articles on mental health.


Prevention of mental illness
WHO points out that the main distinction between mental health promotion and
prevention is in the outcomes that are set75. While mental health promotion aims to
improve positive mental health by increasing psychological wellbeing and resilience
within supportive environments, prevention has the goal of reducing symptoms and
the occurrence of mental disorders. Prevention therefore encompasses measures that:


                                           53
protect the health development of community members; delay the onset of problems;
and minimise the impact of problems once they occur15.


Many countries deal with mental health promotion and prevention together in policy
as there is clearly a large crossover between the two areas. Australia36 107 and New
Zealand15 are unusual in that they treat prevention separately from mental health
promotion. These countries have adopted the three broad areas of primary prevention,
first described by Mrazek and Haggerty123. Thus prevention can be:
  Universal, where interventions are aimed at the whole population or groups that
    have not been identified as high risk
  Selective, where interventions are focused on particular groups or individuals at
    higher than average risk, based on biological, psychological or social risk factors
  Indicated, where interventions target high-risk individuals who may have
    detectable signs or symptoms of mental disorders, but no diagnosable illness




                                            54
The wider determinants of mental health and wellbeing
The overriding importance of the wider socio-economic factors were reviewed on
page 27 in the section on the causes of mental health problems. These determinants
are typically addressed in overall health and public health policies124. For example
Northern Ireland‟s policy19 addresses issues such as parenting skills, good housing,
physical activity and healthy eating, family support and alcohol and drug use.
Sweden adds related topics such as participation in society, healthier working
environment and economic and social security77.


The wider determinants are also mentioned within mental health policy. In addressing
the wider determinants, the Norwegian Mental Health Strategy wants to focus on
ensuring satisfactory housing with sufficient assistance for people with mental health
problems, participation in the labour market and ensuring social contact and
integration64. Australia describes the wider determinants as the psychosocial and
environmental determinants of mental health which include income, employment,
poverty, education and access to community resources23.


Most countries set the overarching goal of reducing inequalities in health, which will
be achieved in large part by improving the physical, social and economic
environments. Thus the achievement of the inequalities goals should also help to
reduce mental health problems125.     An excellent example of this is the English
Programme for Action on tackling inequalities in health126. Some of the many actions
include: providing childcare programmes for teenage parents; tackling and preventing
homelessness; meeting the language needs of asylum seekers and refugees by
providing an online resource of health information in key languages; and enabling
people with health problems and disabilities to move into work through a Pathway to
Work Strategy on rehabilitation.


The wider determinants of mental health and wellbeing also fall within the remit of
the separate group of policies concerned with social justice and social inclusion.
These policies are largely motivated by concerns for human rights rather than general
health or mental health125. They deal with issues, such as poverty, employment,
housing, education and training, crime, social welfare, and community wellbeing.



                                         55
Often these policies do not mention mental health and wellbeing explicitly, but clearly
will have a major influence on it.


England is unusual in having a report which deals exclusively with social exclusion
and mental health76. The purpose appears to have been to ensure coordination across
policy documents and government departments.                 The report, which was
commissioned by the Prime Minister and the Deputy Prime Minister, focused on
people of working age, and was aimed at reducing social exclusion among adults with
mental health problems. It presents 27 action points for which responsible agencies
are identified and achievement dates have been set. These aim to enable people with
mental health problems to enter and retain work and to secure the same opportunities
for social participation and access to services as the general population.




                                           56
Provision of services
Reviewing the details of the treatment of mental illnesses is clearly beyond the
purview of public health policy. However, the planning of health care services and
ensuring that services meet needs is a matter for mental public health policy.
Considerable attention has recently been given to the assessment of the need for
services and the extent of unmet need. Most countries acknowledge that lack of
resources and support has hampered progress to achieving a high quality mental
health service.   New Zealand explains that in large part this is a legacy of the
reorganisation of the mental health services that followed deinstitutionalisation, when
insufficient funds were directed to community care101. New Zealand‟s response to the
inadequacy of the services was to create a Blueprint for Mental Health Services110.
This substantial document describes the kinds and the levels of health care services
needed to realise the objectives of the National Mental Health Strategy, and guides
policy development.


Canada‟s concerns about mental health services are revealed in a recent report which
stated “although dramatic improvements have been made in the past two decades in
the delivery of mental health services and addiction treatment……neither area has
gained sufficient public support or government funding to ensure Canadians obtain
the same quality of services as they do when they receive treatment for physical
illnesses”44. England acknowledged in the late 1990s that services had suffered from
neglect and deterioration127. In consequence the government pledged £700 million
per annum over three years to remedy this25. Norway, in a report submitted to
Parliament in 1997, also identified shortcomings in services at all levels, including
preventive services, services at municipality level, access to specialist services,
duration of inpatient stays and discharge planning and follow up64 and has earmarked
grants for the expansion of services. The Norwegian Parliament, in 1998, adopted a
national programme for a major increase in funding and revision and reorganisation of
the services during the period 1999-200664. Finally, Wales refers to the „Cinderella
status from which mental health has suffered over many years‟26. It reports that
“mental illness services have often received low priority within health and social
services and have suffered from lack of investment”.




                                          57
Several countries stress the need to deliver a more integrated service. Australia,
wants to improve linkages between specialist mental health care workers and primary
care23. Canada reports that one of the major shortcomings is that the system is
fragmented, with an array of services being delivered by a variety of providers “all of
varying capacity and quality, often operating in silos, and all-too-frequently
disconnected    from    the   health   care    system”44.   Wales   acknowledges   that
commissioning mental health services is complex because of the range of agencies
that need to be involved. In response it advocates joint planning by local government
and the health sector128.


Earlier detection of problems and early treatment are also highlighted as important
areas for development. For example, the USA has set targets for increasing the
numbers of individuals who are screened and treated for mental health problems16.
One standard in England‟s National Service Framework is that mental health needs
should be identified, assessed and treated appropriately129. New Zealand identifies
the need to make primary care services more responsive so that they can improve
detection and management of problems15. Australia intends to develop a range of
early intervention strategies suitable for the common clinical conditions in diverse
population groups23.


Most countries comment on the issues of awareness of and access to services. For
example Northern Ireland is establishing a partnership between the health and
voluntary sectors to ensure that information about local services is available and
accessible35. Scotland intends to develop consumer guides to common mental health
problems as well as self-help tools and manuals24. Australia aims to improve access
to all types of care including acute care, community-based care and recovery and
rehabilitation programmes23. This is to be coupled with training programmes for
consumers‟ families and carers to understand signs of illness, onset and relapse and
timely access to services.


Training
Public mental health policy is also concerned with ensuring that the workforce
delivering the public mental health agenda is adequately trained.           When the
deinstitutionalisation process was taking place, many countries found that there were


                                              58
insufficient numbers of adequately trained staff to meet the needs of those being cared
for in the community. Thus, training of the workforce is an important strand of
policy.

New Zealand has developed a Workforce Development Framework which is made up
of five strategic imperatives to increase the capacity and capability of the
workforce130. These include: infrastructure development; training and development;
retention and recruitment; organisational development; and research and evaluation.
Four national centres for workforce development have been established to oversee the
work15. Australia notes that the nature of the workforce delivering mental health care
has changed substantially during the past decade23. Its current strategy therefore aims
achieve the optimal mix of health care workers to deliver the mental health agenda.
The workforce is much more diverse and now includes psychiatrists, nurses,
psychologists, social workers and other allied health professionals. In addition care
has shifted away from specialist mental health services only, to involve much greater
input from primary care. England wants to develop the relationship between primary
care and specialist mental health services25. Wales devotes a substantial part of its
adult mental health strategy to staff development128.       It wants all mental health
professionals to have access to up to date information to ensure that practice is
evidence based, and that quality of care is monitored through clinical governance.
One of the aims of Northern Ireland‟s mental health promotion strategy is to ensure
that all those with a contribution to make are skilled and aware of effective practice in
mental and emotional health promotion35. It specifically calls for assurance that the
training of professionals and volunteers takes into account the needs of high risk
groups and ethnic minority groups and disabled people.


Much of the public health activity to improve mental health, particularly in mental
health promotion, occurs outside of the mental health services. The issue of training
therefore is much wider than for health professionals alone. Much less detail is given
in policy on how the training of stakeholders outside health care will be achieved.
Teachers, social services staff, youth workers, clergy, volunteers, the police and
people in the judicial services are some of the many stakeholders who are expected to
help deliver the mental health agenda.




                                           59
Some countries report on the diversity of training required. For example, Northern
Ireland wants to ensure that community workers and youth workers will be trained in
the early recognition of problems and in effective approaches to support young
people‟s mental health35.    Australia highlights the role of mental health service
personnel in encouraging people in other sectors to consider the impact their work
may have on the mental health of the population23. Several policy documents list the
range of potential stakeholders who will deliver mental health agenda. For example,
Scotland‟s consultation document on children and young people‟s mental health86
identifies a large number of potential stakeholders including teachers and other school
staff, care workers, SureStart workers, police, and youth justice teams. The Child and
Adolescent Mental Health Services (CAMHS) staff are charged with the greatest role
of developing and delivering the training needs of the stakeholders in a variety of
settings. Similarly, Australia‟s mental health promotion and prevention plan gives a
diverse range of people who could be involved, similar to those listed above, but also
includes journalists, editors, employers, policy makers and government ministers.
Unfortunately policies do not contain explicit details of how the training needs of all
stakeholders will be met.




                                          60
Children and young people
Mental health problems are a major cause of morbidity among children and young
people. In the countries studies, the estimated prevalence of mental health disorders
in children and young people range from 10% to 20%. Approximately 20% of
American children between 9 and 17 years have a diagnosable mental disorder in any
given year16.   The National Report on Youth Policy in Norway131 reports that
approximately 20% of Norwegian children and young people suffer from mental
illness and that around 5% have problems so serious that they require specialist help.
Canada reports that the overall prevalence of mental illness in Canadian children and
adolescents, at any given point in time, is around 15%44. Northern Ireland estimates
that between 10% and 20% of teenagers will suffer from depression at some time35.
England states that 10% of children aged from five to fifteen years have a diagnosable
mental health disorder88. Scotland reports that around 10% of people under the age of
19 years have substantial mental health problems85. Direct comparisons between
countries should be made with caution because definitions of the types of disorders
varies between the countries.


Wales27, Scotland86 and England88 all have separate policy documents dealing with
mental health among children and adolescents. Norway, in 2002, reported that it was
preparing a strategic plan for children‟s and young people‟s health, due for
publication in 200342, but we were unable to obtain a copy in English. Ireland‟s
National Children‟s Strategy reports that a working group to advise the Minister of
Health and Children on the development of child and adolescent psychiatric services
was established in 2000132.


The child and adolescent policies recognise that because young people are still
developing socially emotionally and intellectually, mental health problems can have a
greater impact than among adults. England notes that the consequences of mental
health problems including educational failure, family disruption, offending and
antisocial behaviour are far reaching, pointing out that these have consequences for
social services, schools and the youth justice system88. Wales27 and England88 also
point out that untreated mental health problems in children can continue into adult
life, leading to the perpetuation of problems.



                                           61
Several countries discuss factors that increase the likelihood of mental disorders
among children and young people. Norway and Scotland acknowledge that social
disadvantage (including poor educational quality, poor living standards and lack of
social support) and long term family stress can lead to mental health problems in
children, adolescents and young adults20 131. The National Report on Youth Policy in
Norway131 confirms that parental problems, particularly those associated with drug
and alcohol use, and the inability to cope with conflict, lead to the increased
probability of mental health problems in children.        Wales27 identifies high risk
children (those abused, refugees and homeless children) and discusses the impact of
substance abuse among adolescents. It also recognises the impact that becoming a
carer for siblings or a parent has on children and young people27. Inappropriate
responsibility taken on too early may have an adverse effect on a child‟s mental
health.


New Zealand reviews both protective factors and risk factors for mental health
problems in children34. These are organised in several groups such as individual
level, family, school and community. Individual factors include problem solving
skills, school achievement and social competence: school factors include a sense of
belonging, positive school climate and school norms against violence; and community
factors include a sense of connectedness, and strong cultural identity and ethnic pride.
New Zealand acknowledges that it can be difficult to recognise mental health
problems in younger people. Thus it has produced a report to assist those working
with young people to recognise mental health problems and to make appropriate
referral to specialist services133. This not only lists the behaviours which might
indicate a problem, but carefully distinguishes between normal behaviours, those
which should result in the provision of local help and those which need specialist
help.


Despite the level of interest in children‟s mental health, some countries comment on
the deficiency in mental health services. For example, Australia notes that only 29%
of children and adolescents with mental health problems had been in contact with a
health professional36. It therefore aims to ensure that the development of child and
adolescent services, including improved access, is a key component of the mental


                                          62
health services framework23. New Zealand proposes that District health Boards reach
annual targets for children and adolescents accessing specialist CAMHS15.


Wales, in its 2001 policy on child and adolescent mental health services27 comments
that the volume and diversity of services and the number of trained staff at all levels
and in all sectors are too low. Scotland, in a 2003 needs assessment on children and
young people‟s mental health, stated that there was a significant mismatch between
the level of mental health need and the capacity to work with that need85. It also
noted that many groups work in isolation. Thus emphasis is given to the integration
of children services. The Needs Assessment in Scotland led to the creation of a
Framework for Promotion, Prevention and Care86 which is currently out for
consultation. Norway states that although all mental health services are seriously
deficient, the deficiencies are greatest for children and young people131. This is being
remedied through the Expansion Plan for Mental Health 1999-2006 which will
provide services such as more residential and day places for children and young
people and more professional staff for outpatient services (document not available in
English). Canada, in a recent report, is the most forthright. Its dissatisfaction with
current services is great, reporting that “child and adolescent services have been
called the “orphan‟s orphan” of the health care system, a term that has its origin in the
frequent reference to mental health as the “orphan” of the Canadian health care
system”46. Canada reports that mental health services for children and adolescents are
usually delivered through a number agencies which leads to a highly fragmented and
uncoordinated service. Another problem that has been identified in Canada is that
services for children have developed very slowly and only as an adjunct to adult
programmes.


Few countries have targets for mental health in young people. The USA and Northern
Ireland are exceptions.    The USA has one target for children: to increase the
proportion of children with mental health problems who receive treatment. Northern
Ireland in its current public health strategy has 14 key targets for children and young
people18. Although these cover all aspects of wellbeing among this age group, several
specifically measure mental health outcomes. Examples include:
  To have improved the mental health and wellbeing of young people aged 16 and
    24 years by a fifth between 2001 and 2025 as measured by the GHQ 12 Score


                                           63
  By 2015 no more than 25% of those on child and adolescent psychiatry waiting
    lists will be waiting for three months or longer for a first appointment
  By 2025 all children requiring specialised child and adolescent mental health
    services will be able to access them in three months or less


Several countries propose actions to be taken to address mental health problems
among children and adolescents. However, many of the proposed actions are around
the planning and development of initiatives. For example a report from the US
Surgeon General which proposes a National Action Agenda has eight goals and a
series of potential actions134. One of the goals is to “develop, disseminate, and
implement scientifically-proven prevention and treatment services in the field of
children‟s mental health”. All of the proposed actions therefore are about supporting
research and development of effective interventions, rather than initiatives to be
implemented. New Zealand plans to increase and improve specialist mental health
service provision15.    Other proposed actions involve raising public awareness,
increasing the detection of mental health problems in children, improving the
infrastructure for children‟s mental health services and the training of staff.


Scotland‟s consultation document on children and young people's mental health86,
provides the most comprehensive set of potential interventions. The final revision of
these is awaited. Examples of interventions proposed include:
  Development and delivery of parenting programmes.
  Tailored support for children, families and parents at high risk of developing
    mental health problems
  The involvement of children, young people, parents and carers in the
    development of information and resources on mental health issues and also in
    research
  Development of policies on bullying for schools and communities
  Support for schools in developing initiatives such as activities to promote
    emotional literacy or peer support groups
  Counselling for staff and pupils within schools and for staff in the community
  Support for parents on issues surrounding adolescence in schools and the
    community



                                            64
 Development and the dissemination of information on mental health services
  available for children and young people
 Training and consultation on the mental health needs of groups of people
  responsible for children with mental health needs eg care workers, foster parents
  or adoptive parents, social workers, police and children‟s reporters
 Care for children and young people with physical health problems or learning
  difficulties, and their parents
 Ensuring interagency communication following mental health assessment of
  children and young people




                                        65
Older people
Older people, as a group, are thought to be at high risk of developing mental health
disorders.   Depression, anxiety disorders and dementia are common, particularly
among older people with other chronic health problems. Thus older people should
have easy access to the full range of mental health services. England acknowledges
that depression and dementia are the most common mental disorders among older
people, suggesting that 10-15% of older people suffer from depression at any one
time90. New Zealand also reports a high prevalence of depression among this age
group15, although data from Australia suggests that the prevalence falls to less than
4% in those aged over 6589. A report from Scotland suggests that depression affects
3-5% of people over 65 years at any given time, with milder forms of mood disorders
affecting another 10-15%135.


England and Australia review the risk factors for depression among older people36 90.
These include bereavement, retirement, chronic physical health problems, social
disadvantage and social isolation. Under diagnosis of mental health problems among
older people is often a problem, particularly for those living in residential care90.
Scotland points out that many older people simply put up with their symptoms
because they do not realise that they have a disorder which can be treated135.


Three reports from Scotland review dementia135-137. It is estimated that about 5% of
people over 65 years suffer from some form of dementia, with this figure rising to
around 25% among people over 85 years.           Thus, because of the ageing of the
population, the numbers with dementia are rising indicating that by 2040, 2% of the
population will be living with dementia137. Scotland proposes that NHS Boards and
Local Authorities should assess the population needs for dementia and plan
appropriate capacity of services. It also states that NHS Boards should ensure that
services can provide rapid assessment of cognitive impairment, backed up by access
to treatment and follow up135.


Suicide is also a problem among older people. Australia has produced a report on
Ageing and Suicide138, which identifies factors that may contribute to suicide among
older people. These include social isolation, physical illness, psychiatric problems



                                          66
and losses such as bereavement, marital breakdown or financial loss. Scotland points
out that around 25% of suicides occur in older people, although they comprise only
15% of the population135. It also confirms that 90% of older people who commit
suicide have serious depression, and the majority have visited their GP in the three
months prior to their death.


Northern Ireland is the only country to set a target for mental health among older
people18: to improve the heath and wellbeing of older people by one fifth between
2001 and 2025 as measured by the GHQ 12 score. It estimates that, based on 2001
data, 17% of people in this group had the potential to develop or had developed
psychological problems.


Several countries report the need to improve mental health services for older people.
New Zealand intends to improve the quality and increase the availability of specialist
services for older people15. Australia‟s new mental health strategy seeks to ensure
that older people‟s mental health services are developed as a key component of the
mental health services framework23. Northern Ireland identifies the need to remove
barriers to the use of health and social services, such as lack of transport,
embarrassment or lack of information18. It proposes to develop an integrated policy
by involving primary care, community care, acute care, the voluntary sector and
independent agencies. Northern Ireland also proposes increasing services for people
with dementia and their carers.


The English National Service Framework (NSF)90 provides a review of mental health
services for older people. It suggests that a comprehensive mental health service for
older people includes: promoting good mental health; early detection and diagnosis,
an integrated approach to assessment, care planning and treatment planning; support
for carers; and providing readily accessible specialist mental health services for older
people. Wales, in its adult mental health strategy26, discusses plans to develop a
strategy for services for older people with mental illness, drawing on England‟s NSF
for older people and on Welsh District Audit findings.


Australia and England propose actions for mental health promotion targeted at older
people36 90. Australia suggests increasing community awareness and understanding of


                                          67
positive ageing; increasing mental health literacy among older people and promoting
policies and practices that encourage the participation of older people within the
community. England points out that the mental wellbeing of older people will benefit
from general population interventions, but says that issues that need specific attention
are social isolation, bereavement support and suicide prevention. It also suggests that
people who live in residential care and nursing homes or receive day care, should be
given the opportunity to participate in a range of stimulating activities90.


Other proposed interventions include increasing social support and social
connectedness for older people, reducing elder abuse, improving the mental health of
carers (many of whom are older), reducing risk factors for mental health problems and
suicide and early intervention for depression, anxiety and dementia. To achieve these
outcomes Australia plans to include mental health in programmes to promote healthy
ageing, develop programmes to enable older adults to participate in their communities
and to develop and maintain social networks. They also plan to pilot and evaluate
interventions that target high risk older people, such as those with chronic illness, the
recently bereaved or carers.


Finally, early recognition and treatment and access to specialist care are important.
The English NSF describes in detail the nature of depression and dementia and
discusses the diagnosis and management of both diseases90.            Australia plans to
introduce early intervention initiatives that focus on depression and suicide prevention
for older people23. Scotland highlights the need for better recognition of depression
among older people by health professionals, pointing out that this would not only
substantially reduce suffering, but could also have an impact on suicide rates135. Thus
it recommends that NHS Boards should do more to raise awareness of older people‟s
mental health issues and should promote the recognition and treatment of problems at
an early stage.




                                            68
Carers
Carers represent one of the most vulnerable groups in society139. Caring for relatives
with any serious and chronic illness can be particularly demanding and stressful.
Thus all individuals with a demanding carer role are at risk of mental health problems.
England has an entire policy devoted carers91. It reviews the evidence on factors that
help carers to cope and to continue to care. These include: time off from caring; relief
from isolation, and satisfaction with the help they receive from their families and
others; reliable and satisfactory services; information; and recognition of their role
and contribution. The document identifies three approaches: increasing the range and
quality of information sources; improved support, including workplace policies; and
increased choice of support for carers. Carers should also be involved in decisions on
services for themselves and the person they care for. Northern Ireland is working to
develop a Carers Strategy, following the publication of two reports Informal Carers140
and Valuing Carers141, both published in 2001. The principles developed in Valuing
Carers are that: carers will be recognised as real and equal partners in the provision of
care; carers need for flexible and responsive support is recognised; carers have a right
to life outside caring; caring should be freely chosen; and there should be investment
in carers. Northern Ireland‟s proposed actions include increased training, and the
provision of respite care and appropriate household modifications and equipment.
Crisis care services are to be developed to ensure that support is available should
family circumstances change.


Few countries have targets for the mental health of carers. Wales and Northern
Ireland countries want to improve the mental wellbeing of carers as measured by
mental health questionnaires. The target for health inequalities in mental health in
Wales is to increase the mean MCS score for carers by one point by 2012 104.
Northern Ireland‟s new strategy for health and wellbeing, has as one of its objectives:
to improve the mental health and wellbeing of carers by a quarter between 2001 and
2025 as measured the GHQ 1218. A 2001survey in Northern Ireland revealed that
around 30% of carers had the potential to develop or had developed a psychological
disorder. One of the overall goals of the current New Zealand Mental Health Plan,
includes increasing the health status of, and reducing the impact of mental disorders
on carers15.



                                           69
One of the desired outcomes in Australia‟s current National Mental Health Plan23 is
improved support for families and carers, particularly where the carers are children.
Australia plans to provide this support by: developing guidelines for carer plans which
will include regular reviews of their needs; improved respite care and services for the
children of parents who suffer from mental illness; and the involvement of carers in
care planning for their charges.     Wales is also particularly concerned about the
wellbeing of carers, and recognises that services need to respond more effectively to
their needs26. In the UK in 2004 the Royal College of Psychiatrists together with the
Princess Royal Trust for Carers launched a joint campaign entitled “Partners in
Care”142. This aims to highlight the problems faced by carers and to encourage
partnership between patients, carers and professionals. The campaign involves the
production and distribution of leaflets, a video and educational initiatives. Other
countries including the UK countries143-145; Australia and New Zealand146 have
voluntary organisations which provide support for carers.


Involving users and carers
The importance of involving people with mental problems and their carers in
decisions about their care is widely recognised. For example Norway states that
recognition of the user/participant perspective is fundamental to the reform of mental
health care64. The intention is to involve the user/relatives in all aspects of services
such as planning, legislation and treatment. As part of this a new law has been enacted
which codifies and extends the rights of patients. New Zealand15 and Australia23 take
a similar approach and plan to increase consumer, relative and carer participation in
policy development and service planning, delivery and evaluation. They specify that
carers and consumers should be involved in the development and delivery of
undergraduate, postgraduate and ongoing medical training as well as that of other
groups who deliver services. Wales recognises that service users and carers are often
the first to recognise problems and to have most insight into their causes26. Thus it
intends that user/carer involvement should occur at all levels from the National
Assembly through Health Authorities to unit and sector teams26.




                                          70
Non-governmental organisations
Mental health is a field within which there are many dozens of non-governmental
organisations (NGOs) in each country. Examples of the types of organisations are
listed in Appendix 2. They address differing, if overlapping, aspects of mental health.
For example the US National Mental Health Association147 works to improve the
mental health of all Americans through advocacy, education, research and support for
those providing services. Mental Health Ireland148 has a similar aim but acts through
identifying the needs of persons with mental illness, their families and carers and
advocating their rights.     Some organisations focus on specific mental health
conditions such as the Schizophrenia Society of Canada149. Others deal with issues
raised by mental illness, such as Caring for Carers in New Zealand146 or Stigma.org
in the UK150.


In addition to independent national organisations there are many national umbrella
organisations which represent the interests of local groups at regional and national
level. Examples include the Depression Alliance in the UK151, Platform in New
Zealand152 and the National Stigma Clearinghouse in the USA153. There are also
international umbrella organisations such as EUFAMI, (the European Information
Desk on Mental Illness)154 and The World Federation for Mental Health155. The
latter, founded in 1948, currently has members in 112 countries on six continents and
organises World Mental Health Day.


Non-government organisations have a longstanding association with mental health
services. For example, Australia, in its first National Mental Health Policy in 1992,
acknowledged the contribution of non-government organisations in providing support
services for those with severe mental health problems, in advocating for services to be
more responsive and in educating and supporting carers105. However, it concluded
that they would require increased support, funding and opportunities for involvement
in decision making if they were expected to continue their role. Australia‟s current
strategy calls for the continued development of the non-government organisations to
clarify their role in support, advocacy and psychological rehabilitation and to increase
the capacity of the organisations to support consumers, carers and families23. Non-
government organisations also have a prominent role in New Zealand. With one third



                                          71
of the total mental health budget being spent on non-government organisations, New
Zealand has one of the largest NGO mental health sectors in the developed world15.
Norway also recognises that these organisations make important contributions and
that they are not well supported64. Thus it has earmarked state funding for them.
Wales also supports the role of the voluntary sector and insists that they must be
involved in service delivery in all regions of the country26. The range of services
includes supported housing, employment schemes, drop-in centres, outreach services,
counselling, self-help and self-management initiatives, social support and advocacy26.
However it also states that the voluntary sector must recognise the legal constraints
and responsibilities of the statutory sector. Ireland made a commitment to the transfer
of funds for voluntary mental health agencies to the Health Boards in its strategy
Working for Health and Wellbeing156. The intention was to develop constructive
relationships between voluntary and statutory services.


England is notable for its efforts to support NGOs. It established a Compact between
government and the voluntary and community sectors in 1998, which sets out a series
of undertakings with which all groups agree157.       Although covering all 500,000
voluntary and community organisations, mental health groups will be represented.
Through the ChangeUp programme, launched in June 2004, £80 million was invested
to develop the capacity of the voluntary and community sector158. However an early
evaluation identified a number of challenges including: the lack of a focus for sector
ownership; the complexity of the fund management; and the lack of mechanisms for
coordination. To overcome these challenges a new programme, Capacity Builders,
has been established159. More recently, a consultation document published by the
Home Office, provides proposals to strengthen partnerships between the voluntary
sector and the Government157.




                                          72
Stigma and discrimination

Describing stigma and discrimination
Stigma and discrimination have always been associated with mental illness. Australia
highlighted stigma in its 1992 National Mental Health Policy, reporting that people
with mental health problems and their carers experience substantial stigma105. While
all countries are now concerned with stigma, few give a clear definition in policy
documents.    New Zealand in the Orientation Kit for its anti-stigma campaign160
defines stigma as a “mark of shame, disgrace or disapproval”. Scotland suggests that
stigma refers to negative stereotyping and its consequences51. England notes that
stigma has been understood as “the relationship between characteristics of a person
and socially constructed negative stereotypes”37.         Other countries discuss the
characteristics and consequences of stigma. For example the Report of the Surgeon
General on Mental Health47 outlines the ways in which stigma is manifested through:
bias, mistrust, embarrassment and fear of violence in individuals with mental
disorders. This often leads to avoidance of socialising, living or working with people
with mental disorders, particularly those with severe disorders. Thus patients‟ access
to employment, training and housing is reduced. All of these in turn may lead to low
self-esteem, social exclusion and hopelessness. In the most extreme cases stigma can
lead to overt discrimination and abuse. Wales identifies the cause of stigma as the
public misperceptions of mental illness which result form misunderstanding and lack
of knowledge128. Scotland reports that the consequences of stigma are that attitudes
and beliefs lead to labelling, setting apart, devaluing and discrimination51.


The discrimination that results from the stigma surrounding mental health problems is
not well described in policy. New Zealand describes discrimination as the systematic,
unfair treatment of people because they are different160. England adopts the UN
definition that discrimination is the “less favourable treatment of persons”37.
Discrimination can present in different ways: people with mental illness may be the
subject of ridicule, harassment and abuse, or they may be forgotten, ignored or denied
access to opportunities that other people take for granted.        They also encounter
negative images of them in the media, literature and conversation. England points out
that the relationship between attitude (eg prejudice) and behaviour (eg discrimination)



                                           73
is complex, stating that people can be prejudiced and behave fairly or can discriminate
unintentionally37. It adds that the occurrence of discrimination will depend on many
factors such as the social acceptability of discrimination, the likelihood of being
observed and the possible costs of the action.


The consequences of stigma and discrimination against people with mental health
disorders can be far reaching. The Social Inclusion Unit in England76 found that that
stigma and discrimination can have a greater impact on people‟s lives than the mental
health problems themselves. A recent report from New Zealand includes a quote
from the 1996 Mason report “there is no doubt that the feeling of alienation created by
stigma is one of the significant reasons cited for loss of hope and relapse by those who
experience mental illness”161. This concurs with Australia‟s view that stigma and
discrimination substantially adds to the burden of mental illness23. Australia also
acknowledges that the fear of the stigma attached to mental health problems is a
powerful disincentive to early treatment and a major factor in treatment delay55 105.


Several countries have conducted surveys to establish views on mental illnesses and
the prevalence stigma. The USA in particular, has monitored stigma since the 1950s
through national surveys to track mental illness47. The early surveys showed that
mental illness was stigmatised, and that this stigma was coupled with a poor
understanding of the nature of mental illness. By 1996 the surveys showed that
understanding of mental illness had improved substantially but the increases in
knowledge had not defused the issue of stigma. Other countries have also found that
stigma remains a problem. An Irish survey in 1999 found that there was limited
knowledge about mental illness and that negative attitudes to those with mental health
problems were common162. Canada, in a 2002 survey, found that the proportions that
would be secretive about receiving depression counselling had increased from
1992163. The Department of Health in the UK has conducted mental health surveys
since 1993164. The consistent findings are that, while people are generally caring and
sympathetic about mental illness, there is concern about the danger posed by some
people with mental illness25. More worryingly the most recent survey shows that
levels of tolerance and support for people with mental illness are falling164. However
surveys in Scotland found reductions in concerns about violence among people with



                                           74
mental illness, as well as an increase in willingness to talk about mental health
problems165.


The US Surgeon General‟s Report, in 1999, recognised that there is no simple way to
reduce the stigma associated with mental illness, and that while it was widely
assumed that increased knowledge on mental illness would lead to the elimination of
stigma, this has not occurred47.       The report concludes that knowledge of mental
illness alone is not enough and that broader knowledge is required, particularly to
redress public fears. New Zealand concludes that the problem is complex and stated
that “we need to be on guard against simple solutions”110. Australia acknowledges
that increased knowledge may not change attitudes or behaviours and suggests further
research is needed to identify the effects of increased knowledge89.


Some countries also discuss the problem of institutional stigma. Australia, in 1992,
stated that stigma had led to inadequate resourcing of the mental health services105.
Its most recent mental health policy, which states that the attitudes of the mental
health workforce can perpetuate stigma, indicates that the problem has not resolved23
109
      . It concludes that a mental health workforce that actively works against stigma is
fundamental.


Commitment to reduce stigma
All countries agree that the stigma surrounding mental illness must be tackled and the
principles of equity should be applied to people with mental illness. Since 1992,
Australia‟s policies have clearly stated that every person with a mental disorder
should have the same civil, political, economic, social and cultural rights as everyone
else. New Zealand also identified the need for action on stigma in its 1994 mental
health strategy101. In recent years reducing stigma has become a major thrust of
mental health policy in most other countries. For example, eliminating stigma and
discrimination was one of the two key priorities in the initial phase of Scotland‟s
National Programme for improving Mental Health and Well-being in 2001 - 2003,
and remains one of the four key aims for the period 2003 to 200624.




                                             75
Interventions to tackle stigma
Several countries have launched information campaigns to reduce stigma and
discrimination. For example, in Norway an information strategy is seen as an
important part of reducing the problem of stigma64. It reports that “higher awareness
will reduce the harmful effects of stigma and discrimination by dismantling myths and
putting a public face on mental health and mental health disorders”. Northern Ireland
is currently developing a public and professional mental health awareness campaign
to reduce stigma35.

New Zealand has a longstanding National Plan to counter stigma and discrimination.
The third Plan is due for publication in 200538. The current Plan develops the Like
Minds Like Mine Project, an awareness raising strategy which was introduced
following the 1996 evaluation of mental health policy. At that time it was anticipated
that an awareness raising strategy would be sufficient to reduce stigma.          The
subsequent strategy however encompasses much more than awareness raising. It
focuses on reducing discrimination, and has incorporated a human rights model and
also the social model of disability which features in the New Zealand Disability
Strategy166. The aims of the Plan are to ensure that all people who have experienced
mental illness will gain equality and respect and will have the same rights as others;
that the public and private sectors will value and include all people who have
experienced mental illness; and that there will be a greater understanding, acceptance
and support for all people who have experienced mental illness. One of the objectives
of the plan is to engage leadership and participation by individuals and groups of
people with experience of mental illness. The Plan also advocates the development of
non-discriminatory policies and practices, and the use of the mass media and
community education to reduce social exclusion of people with experience of mental
illness.


England also has a long history of implementing strategies to reduce stigma and
discrimination.   In 1992 one of the three broad aims of its Defeat Depression
Campaign was to reduce the stigma associated with depression. Following this,
Changing Minds, a five year awareness raising campaign was launched in 1998, by
the Royal College of Psychiatrists167.    Another campaign, Mindout - for Mental
Health, commissioned by the Department of Health was a collaboration of a range of


                                         76
stakeholders including the voluntary sector, youth and student organisations and
independent companies. The campaign ran for three years up to 2004. The aim of the
campaign was to raise awareness, challenge people's assumptions, and provide
practical advice to help people make positive changes in their attitudes and behaviour.
England‟s current response to the challenge of tackling stigma is led by the National
Institute for Mental Health in England (NIMHE) which has developed a strengthened
programme to tackle stigma and discrimination. It conducted a scoping review of
approaches to tackling stigma and discrimination, and established six principles that
underpin best practice168. These principles include: involve users and carers; create
national programmes that support local action; address behaviour change as well as
raising awareness; and plan and fund long term programmes. A strategic plan From
Here to Equality, developed from the findings of the review, was subsequently
published by the NIMHE in 200437. This presents a social model of disability which
states that discrimination does not only arise through impairments caused by illness,
but also by the barriers and prejudice placed in the way of those with illness. The new
programme is designed to support local practitioners in all public agencies in
collaborative working and will have a national lead supported by regional workers.


The Scottish See Me campaign, launched in 2002, is funded by the Scottish Executive
and run by an alliance of five mental health organisations169. The campaign uses
multimedia broadcasting to convey the anti-stigma message combining a national
publicity programme with local and national anti-stigma actions. It was developed
through consultation with people who have experienced mental health problems and
includes people who are prepared to talk to the media about the impact stigma has had
on their lives. The Welsh adult mental health strategy, calls for practical approaches
that focus on building positive relationships and mutual understanding between those
with mental illness and the wider community26. It suggests working with the private
sector to promote mutual understanding, training and employment opportunities and
improving links between mental health groups and other services and organisations
such as housing and leisure services.


There are many non-government organisations which are working to tackle stigma.
These vary from local projects to international organisations. For example a scoping
review in the UK was able to contact 75 local projects dedicated to dealing with


                                          77
stigma37.   The Resource Centre to Address Discrimination and Stigma is a US
Department of Health initiative to provide help to those wishing to develop and
implement antistigma programmes170.


The voluntary sector also has a role in tackling stigma. Some organisations, for
example the National Stigma Clearinghouse in the USA153 and Sane171 in Australia,
use volunteers to monitor the media for instances of stigmatisation. Individual
instances are carefully assessed and serious cases are publicised through articles
letters and placement on websites. The responsible media groups or businesses can be
contacted to explain the nature and consequences of stigmatisation. Any responses
from these groups are posted on websites. Finally the World Psychiatric Association
runs the „Open the Doors‟ campaign, an international initiative to reduce stigma for
people with schizophrenia149. The number and diversity of these organisations make it
difficult to provide a concise summary of their activities and the impact they have.


Evaluation of national campaigns
England has carried out major evaluations of its campaigns. The impact of the
Changing Minds campaign is uncertain. A survey conducted prior to the campaign
revealed that stigmatising attitudes were common in men and women of all age
groups in all parts of the country172. A second national survey conducted in 2003
revealed the same pattern of responses but noted small reductions in the percentages
of people reporting negative opinions, especially concerning difficulties in
communication with people with mental illnesses. However, this is in contrast with
the recent Department of Health triennial survey of public attitudes towards people
with mental health problems which showed some decline in tolerance of people with
mental health problems since 2000164.


More recently the report on Mental health and Social Exclusion76 noted that
England‟s efforts to tackle stigma had not always been well coordinated, and has
focused on education and awareness rather than achieving behavioural change,
concluding that the two key lessons from Mindout - for mental health were the need
for longer term funding and rigorous evaluation. The Report also describes work
done by the NIMHE in England reviewing national anti-stigma campaigns45. The
study estimated the spending per head of the general population by taking the


                                          78
approximate spending on the campaign divided by the population of the country.
Thus it estimated that the English Mindout - for mental health campaign had an
investment of 1.44 pence per person; Scotland‟s See Me campaign received 13 pence
per person and New Zealand‟s Like Minds, Like Mine received 36 pence per person.
Thus the NIMHE concluded that the average spending on mental health awareness in
England is lower and more short term than in countries with more successful
programmes76.


The Scottish See Me campaign169 was launched in 2002 and is intended to be a long
term campaign. However, early indications are that it may be helping to change
attitudes. The Second National Survey of Attitudes to Mental Health and Mental
Health Problems165 published in 2004, reported that there are signs that perceptions of
mental ill-health improved between 2002 and 2004. The authors acknowledge that
they cannot be certain what brought about the changes, or whether they represent a
long term change, but report that “it seems likely that the work of the National
Programme and, in particular the See Me campaign has helped to reduce some of the
stigma surrounding mental ill-health”.


New Zealand‟s longstanding National Plan to counter stigma and discrimination38
has also been carefully evaluated since the introduction of the Like Minds Like Mine
Project. The evaluation of the first phase (the awareness raising campaign) found
extremely high levels of recall and substantial increases in positive attitudes to mental
health38. However, an independent review revealed that the campaign had a minimal
effect in increasing the acceptance of people with a diagnosis of schizophrenia. This
in turn raised concerns that the campaign might be fostering a concept of acceptable
and non-acceptable mental illness116. In addition it was noted that “people with the
experience of mental illness were asking when they will see accompanying changes in
actions and behaviour”. Thus the programme was developed to become a multi-
faceted programme for action, with greater emphasis on tackling discrimination.
More recently the Mental Health Commission has completed another review of all
ongoing activities, the roles and responsibilities of those undertaking the work, the
impact of the interventions and gaps still to be filled.        Thus the Commission
highlights the need to address issues around leadership an coordination of activities161.



                                           79
Need for further development
Some countries agree that much is still to be done to reduce stigma and
discrimination.   England has reported that more investment is required76.    New
Zealand, which has the most well developed strategy, is not complacent. Its current
strategy, which reports that much of the groundwork of awareness raising has been
done, has shifted the emphasis towards reducing discrimination, a more difficult
problem to address173.




                                        80
Suicide
Prevention of suicide is a major public health concern in all of the countries studied.
Suicide is the thirteenth leading cause of death worldwide, and the seventh leading
cause of death in the European Region81. Suicide is a complex problem which
involves biological, psychological, social and spiritual factors174. It is a major cause
of death among people with mental illness, particularly among those suffering from
depression. WHO estimates that 15 – 20% of people with depression commit
suicide11.


Most countries describe the scale of the problem and the trends in suicide, as well as
the profound effect that it has on families, communities and society as a whole.
Australia, for example, notes that although the overall rate of suicide has remained
relatively stable for many years, trends within groups shows a fall in the suicide rate
among older people, but a substantial increase among young men, with a trebling of
deaths in the 15 – 24 years age group in a forty year period52. Scotland charts trends
by gender and age group over a twenty year period, and also gives international
comparisons32. Japan is particularly concerned about the increase in suicides, noting
that the number of deaths from suicide is around three times higher than the number
of deaths from road traffic accidents17. Canada has recently estimated that suicide
deaths and suicide attempts costs the Canadian economy more than $14.7 billion per
year174. Many countries, including Norway, England, New Zealand, Australia and
Scotland report increases in suicide in recent decades, particularly among young
men28 29 32 52 64.


The number of suicides and patterns of suicidal behaviour varies between countries
studied. The WHO has produced a comprehensive analysis of suicide rates in all
countries175. This demonstrates a wide variation in the frequency of suicide, the age
distribution and in the overall trends11. This is also true of the countries studied in
this report. For example Figure 1 demonstrates that there is a three fold variation in
the frequency of suicide.    The WHO data also show that these countries show
differing patterns in age distribution and in trends over time175. The data suggest that
the aetiology is complex and may differ between countries.




                                          81
Figure 1


                     International comparison of Suicide rates
                                (per 100,000:WHO)

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Risk factors
Some countries discuss the risk factors associated with suicide. The Consultation
Document for Scotland‟s policy176 lists the main risk factors in Scotland as:
  socio-demographic, where higher suicide rates are associated with lower socio-
    economic status, unemployment, divorce, and some specific occupations such as
    medical and allied professions and farming among men and women and nursing,
    education/health/welfare service employment among women
  psychiatric ill-health, where current or former patients have a ten fold higher risk,
    and those discharged within the previous month have an even greater risk
  previous self harm, where the suicide risk is estimated to be between ten to thirty
    fold
  substance abuse, where the relationship between suicide and alcohol or other drug
    misuse is well established.




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Australia also reviews risk factors for different population groups52. For example, in
addition to the factors listed above, young people are at higher risk from suicide if
they have suffered from physical or sexual abuse, have impaired parent-child
relationships, experienced parental loss through separation or divorce, have parents
with mental disorders or harmful drug use or have problems involving violence.
Other risk factors include biological or genetic predisposition, feelings of
hopelessness, social isolation and access to a means to suicide81.


Protective factors
Canada, Australia and New Zealand discuss factors that protect against suicide.
Protective factors are those that enhance resilience and counterbalance risk factors174.
New Zealand points out that less is known about the protective factors that increase
resilience to suicide behaviour177, but emotional wellbeing, good coping skills and
problem solving behaviour, social integration, secure cultural identity, family
connectedness, physical wellbeing and a drug free environment are all important81 177.
Suicide rates can also be reduced if depression and anxiety are treated effectively with
antidepressants and psychotherapy. New Zealand also lists potentially protective
factors for older people, a group at higher risk177. In addition to having supportive
relationships, other factors include participation in organisations and having a hobby,
adequate pain relief, good palliative care, early, adequate and sustained treatment for
depression, and restricted access to means of suicide, particularly guns for older men.


National policy on suicide prevention
Several countries including England28, Scotland32, Australia33 52 53 and New Zealand29
30 117 177
             have stand alone policies on suicide. Of these, Australia‟s policy is the most
detailed.      Australia Life (Living is for Everyone) – suicide prevention 2000, is
comprised of a series of three documents; Learning about suicide52; Building
partnerships53; and Areas for action33. New Zealand‟s current policies are concerned
with youth suicide29 30, one for all young people and one for Maori youth. However a
consultation document, New Zealand Suicide Prevention Strategy A Life Worth
Living117 was published in April 2005. This comprehensive strategy was developed in
response increasing problem of suicide in New Zealand and the need to address in all
age groups.



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We believe that we may not have had access to all policies, due to difficulty in
obtaining English language documents.         For example, Denmark‟s current public
health policy73 refers to an Action Plan entitled Proposal for action plan for the
prevention of suicide and suicide attempts in Denmark which was published in 1998,
but an English translation of this document cannot be traced. Similarly, Norway
reports on the evaluation of its Plan for Suicide Prevention 1994 – 1999178, but no
current policy has been identified. Finally, Finland which was the first country to
implement a comprehensive programme, reports on their suicide prevention project
which ran from 1986 to 1998, but we were unable to obtain a more recent policy179.


Japan, Northern Ireland and Wales include suicide prevention in their overall mental
health polices.   Finally, Canada and the USA have begun work on developing
comprehensive policies. Both countries have produced preliminary documents: the
Blueprint for a Canadian National Suicide Prevention Strategy174 and the US
National Strategy for Suicide Prevention: Goals and Objectives for Action180.


Targets
The WHO has encouraged the use of targets for suicide since the mid 1980s when it
included a target on suicide in Health for All by the Year 2000181. Target 12 of the 38
targets set for the European Region included the statement that “by the year 2000, the
current rising trend in suicide and suicide attempts should be reversed”. This was
reiterated in the European Region‟s Health for All targets for the 21st Century where
the target for improving mental health states that “suicide rates should be reduced by
at least one third, with the most significant reductions achieved in countries and
population groups with currently high rates”103.


England has one of the lowest suicide rates in Europe but Saving Lives: our healthier
nation set a target to reduce the suicide rate by at least one fifth by 201070. This target
has been carried forward in the National Service Framework on Mental Health25 and
the more recent Suicide Prevention Strategy28. The recently published health targets
for Wales includes one to reduce frequency of suicide (including undetermined
deaths) at all ages by at least 10 per cent by 2012104. This ambitious target was set
despite little progress being made in recent years and the failure to meet the 2002
target104. Japan‟s target is to reduce the number of persons who commit suicide from


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31,755 (1998 data) to 22,000. The USA has separate targets on suicide for adults and
adolescents. For adults the target is to reduce the suicide rate from 11.3 per 100,000
of the population (1998 data) to 5.0 per 100,000 of the population. For adolescents
the target is to reduce the 12 month average of adolescents who attempt suicide from
2.6% to 1%16. Scotland‟s target is to reduce suicides by 20% by 201332. Scotland
also had a target to reduce the rate of suicides among young people as one of the
milestones for improving the health of young people in the Social Justice
Framework182. This target has been retained in the proposed indicators of health
inequalities in Scotland, as an indicator of mental health in young people183. Northern
Ireland has recently set targets to reduce the number of suicides by 50% for all
persons and for males aged 15-44 years. In 2002 the age standardised suicide rate
was 9.5 deaths per 100,000 for all persons and 25.8 per 100,000 for males aged 15-44
years. Other countries have a series of goals, aims and objectives for their strategies
but no numerical targets.


Strategies to reduce suicide
The strategies proposed to reduce suicide are very similar across the countries studied
and share a number of common themes. We have identified six broad areas for
action. The summary is based on the suicide prevention strategies from Australia33,
England25   28
                 , New Zealand29-31   117
                                            , Scotland32, Northern Ireland‟s mental health
promotion strategy35 and Japan‟s overall public health policy17. It also draws on
recommendations for action from WHO81, a report from the Irish National Taskforce
on Suicide184, a document from the US National Council for Suicide Prevention
which has been endorsed by the Surgeon General 180, and a Blueprint for a Canadian
National Suicide Prevention Strategy from the Canadian Association for Suicide
Prevention174. Not every country includes all of these categories as topics can be
fitted into different groupings. Further, because some of the proposals are taken from
developmental work, some of the actions proposed in this review are not necessarily
in place, but proposed as the way forward.


Education and public awareness
All countries want to raise awareness and understanding about suicide.               Most
countries propose that this should be done at both national and local level, through
large scale campaigns and through local awareness raising work. Several countries


                                                85
suggest that increased awareness and understanding can lead to the early recognition
of problems, both in patients and their families. Scotland also suggests that awareness
raising provides a means of encouraging people to seek help early. The USA and
Canada stress the importance of conveying the message that suicide is preventable so
that people are made aware that individuals and groups can play a role in prevention.


Mental health promotion
Some countries suggest that improving the mental health of the population as a whole
can reduce suicide. Mental health promotion, therefore, is a major component of
suicide prevention policy. The WHO, England, Scotland and Ireland have objectives
to promote mental wellbeing in the wider population, and within high risk groups,
such as socially excluded or deprived groups, people who misuse drugs and alcohol,
survivors of abuse, and those who have been bereaved by suicide. New Zealand‟s
youth suicide prevention strategy stresses the importance of strengthening families
and communities to prevent young people becoming at risk of suicide. Northern
Ireland suggests outreach services for young people in need. Proposed strategies to
improve the mental health status of the population include population approaches
across the lifespan in different settings; community mental health promotion
initiatives; parenting skills and support for families with a high risk individual.
Several countries including Canada, USA, New Zealand and Scotland acknowledge
the importance of reducing stigma and discrimination to reduce suicide. Apart from
the stigma associated with mental illness, additional stigma may be encountered by
people who have attempted suicide, or among those who have lost a family member
through suicide.


The media
The way suicide is portrayed in the media is important, as publicity about suicide and
the portrayal of suicide in the media can increase suicidal behaviour, especially
among young people. However, the media can also have a positive role180. All
countries stress the need for supporting media reporting on suicide and attempted
suicide. Japan calls for the ethical control of the media. Specific measures to support
the media include Scotland‟s call to develop guidelines, based on international
evidence, for a “code of conduct” on the depiction and reporting of suicide to ensure
informed and sensitive reporting. The New Zealand Ministry of Health has already


                                          86
developed a document to provide guidance for the media185. The USA suggests that
journalism schools should adequately address the reporting of suicide in their
curricula. The English strategy lists key points from guidance currently available.
These include reducing sensationalism and positive tone in reports on suicide;
promoting the inclusion of facts on suicide; and the avoidance of reference to the
means of suicide.


Reduce access to lethal means
Most policies include efforts to reduce access to lethal means and methods of self
harm.    Some interventions require changes in legislation and some call for
environmental modification. There is evidence of success in reducing suicide with
specific measures being taken. For example, reduced access to barbiturates among
Australian women, limiting access to large amounts of paracetamol and asprin
through introducing a maximum pack size for over the counter sales in the UK,
reduced access to firearms by children in the USA, and safety barriers erected on high
buildings and structures. The introduction of the less toxic natural gas for domestic
use in the UK was also associated with a reduction in deaths from suicide.


Other actions include ensuring that service providers, particularly the prison service,
police and health professionals minimise the risks of people in custody or in
healthcare settings, particularly against suicide by hanging or strangulation. This may
involve structural change such as the redesign of windows or furniture. England and
New Zealand call for increased liaison with the motor industry to reduce deaths from
motor exhaust gas, based on the evidence that the introduction of catalytic converters
for environmental reasons has led to a reduction in death by this method. Some
countries also promote public information campaigns designed to reduce access to
lethal means within the home, in particular providing advice to caregivers of
individuals at high risk about actions they may take.


Service provision
Early detection of depression and mental illness
Early intervention and support may reduce the risk of suicide. This may be achieved
by awareness raising at the national level and at the local level by improved training
of staff in various settings in the detection of problems, and the provision of support


                                          87
for those experiencing mental health problems or emotional or psychological distress.
Japan‟s strategy on suicide is based on the early detection and treatment for
depression as depression is regarded as one of the dominant causative factors in
suicide.


Reduce risks among high risk groups
Several high risk groups are identified. England wants to reduce the number of
suicides among people who have had contact with the mental health services within
the previous year. The USA reports that among older people who committed suicide,
75% had visited a physician in the month prior to their suicide. People who have self
harmed in the past year are also at risk. Some of the proposed interventions in the
English strategy are: outreach teams to prevent loss of contact with high risk
individuals; prompt access to services; follow-up within seven days of discharge from
hospital for patients with severe mental illness or a history of self harm; and patients
with a recent history of self harm receiving a supply of medication covering no more
than two weeks.


England includes young men as a high risk group, and suggests that National Institute
for Mental Health in England (NIMHE) should work closely with schools, colleges
and universities to promote mental health promotion, support the development of
counselling and include risk assessment training in counselling services. Strategies to
reduce suicide among prisoners include improved screening to detect mental disorder,
risk of suicide or self harm and substance abuse, and access to counselling.


England, Australia and New Zealand highlight the special needs of rural and remote
communities, including farmers and farm workers. Proposed interventions include
crisis support for rural health professionals, improved access to mental health services
from remote communities, and increased training in mental health promotion, early
detection and intervention for school personnel and welfare and community workers.
Finland‟s proposals for the development of tele-psychiatric facilities and telematic
counselling could be a solution to this62.     Both Australia and New Zealand are
concerned about their indigenous people, who have high rates of suicide.           New
Zealand even has a separate strategy for young Maori Kia Piki Te Ora O Te
Taitamariki Strengthening Youth Wellbeing30.


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Access to services
Canada and Scotland emphasise the importance of crisis intervention and support.
Scotland highlights the need for public awareness of services and knowledge about
points of contacts, in addition to ensuring that effective services are in place. Rapid
access must be accessible through phone-lines and 24-hour services. In addition
personnel who respond in crisis situations must be appropriately trained and sensitive
to the needs of the client. Japan stresses the need for detection of problems at an early
stage and directing people into appropriate care. Follow-up after discharge of people
with severe mental illness or a recent history of self harm, and outreach services to
ensure contact is maintained is also important. Japan also wants to ensure support for
those who have survived suicide attempts.


Support following a completed suicide or suicide attempt
Some countries propose interventions to increase support to those who have been
bereaved by suicide, both in the short term and longer term. Japan and New Zealand
point out that effective bereavement support can help to minimise the risk of suicidal
thinking and behaviour among family and friends. Interventions include improved
training for people coming into contact with those bereaved by suicide, such as
personnel from funeral directors, churches and schools. Scotland highlights the need
for an integrated response from support organisations, and states that the role of the
agencies involved should be identified within local plans. Communities should be
given support to develop self-help and support groups for those affected by suicide.


Training
Early recognition of problems, assessment and referral for specialised assessment and
treatment can prevent suicidal behaviour. Some countries suggest tailored training for
a range of people who come into contact with those at risk. Target groups include
health professionals in emergency departments, mental health care services and
primary care; people working in the community such as teachers, youth workers,
clergy, police and counsellors. The USA also suggests educational programmes for
family members of individuals at high risk. Canada proposes to develop guidelines
for the assessment of suicidal behaviour across all age groups in different settings.
Northern Ireland specifically calls for awareness training for teachers and youth


                                           89
leaders, health and social services personnel and staff in the voluntary sectors who
work with high risk groups. It also suggests depression awareness training for GPs
and working with the prison service and police to ensure that all possible steps are
taken to minimise the risk of suicide in people in custody.


Surveillance and research
Several countries point out the importance of improving the quality of data collected
on suicide, suicidal behaviour, on interventions implemented and in identifying areas
for increased action and support. All countries highlight the need for further research
into suicide prevention. The USA wants more information on the differences in rates
between different group, locations (for example rural or urban) and the settings in
which people with suicidal behaviour were cared180. High priority topics include:
preventable factors in overdose before and after admission to hospital; the use of
firearms in suicide; and evaluation of preventive interventions. Ireland‟s National
Task Force on Suicide states that more funding is required for research on risk factors,
proactive factors and preventive strategies within Ireland. One of the five goals of
New Zealand‟s youth strategy is on information and research. New Zealand proposes
to promote research into the design and evaluation of suicide prevention and
intervention initiatives, including evaluation of school based programmes, evaluation
of culturally–specific programmes and evaluation of treatment studies for young
people at high risk of suicide. New Zealand wants to make research into suicidal
behaviour among young people a priority. Specific topics that are suggested include
suicide among Maori and Pacific people and other ethnic groups, sexual orientation
issues, cultural alienation, gender differences, cluster suicides and contagion, and the
effect of contact with the police and justice system.




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Attempted suicide and deliberate self harm
Attempted suicide and deliberate self harm are a major problem. A European report
estimates that the frequency of attempted suicide may be up to ten times that of
completed suicide186 while Australia reports that admissions to hospital because of
deliberate self harming behaviour is 17 times more common than death due to
suicide187. Australia also notes that data for suicidal behaviours show distinctly
different patterns from those of suicide52. For example, deliberate self harm is much
more common among women than men, and young people have substantially higher
rates than adults. Ireland points out that it is unusual in that what it terms as
parasuicide is almost as common among men as women184. Data on non-fatal suicide
acts are usually for hospitalisations due to self harm, so this does not reflect the true
number of people affected, as many are not admitted to hospital. In response to this
England has recommended that a National Collaboration is set up to monitor non-fatal
deliberate self harm28. Information on the frequency of deliberate self harm across the
countries is best described as limited.


Deliberate self harm is most commonly referred to as a risk factor for suicide, rather
than a health problem in its own right. For example Australia reports that it is the
strongest risk factor for death by suicide33. England‟s National Suicide Strategy
proposes that attention be focused on those who deliberately self harm as a means of
reducing the risk of suicide28. Scotland‟s suicide prevention strategy focuses
specifically on those aspects of deliberate self harm which relate to the risk of
suicide32.


Defining non fatal events is recognised to be difficult. A working Group of the World
Health Organisation defines attempted suicide as all non-fatal acts which were
intended to cause self harm186. This includes attempted suicidal acts which are
interrupted by others before self harm occurs. Scotland‟s definition focuses on non-
fatal acts intended to cause self harm and implies that self harm has resulted32.
Ireland defines parasuicide to include failed suicide and those who self harm without
the intention to die184. New Zealand uses the term intentional self harm to encompass
both failed suicide and self harm behaviours where suicidal intent is ambiguous or



                                           91
absent117. The emphasis is on violent behaviours that result in injury. The self
harming behaviours include self-cutting, intoxication and self hitting.


Scotland‟s consultation for the Mental Health Programme describes risk factors for
deliberate self harm176. Low socio-economic status is associated with deliberate self
harm, particularly in city areas of high deprivation which have high unemployment,
social exclusion and lack of amenities. Stressful life events, particularly loss in
interpersonal relationships, poor physical health, marital and sexual difficulties and
material deprivation are also associated with deliberate self harm. Ireland also
describes socio-economic factors such as unemployment, low educational attainment
and overcrowded housing184. Unusually New Zealand identifies the individual
motivations for self harming. These include reducing tension, reducing feelings of
unreality and punishing oneself117.


Apart from the limited information given above, few review in detail the scale and
nature of the problem, nor do they present specific strategies to address the problem.
Australia has a commitment to reduce the incidence of non-fatal suicidal behaviour.
However the actions to tackle the problems are dealt with in a joint section on suicide
and self harm, and there are no separate actions to tackle self harm. Ireland‟s 1998
Taskforce on Suicide184 does have a section dealing with the prevention of parasuicide
which identifies that issues such as unemployment, education, housing and the
wellbeing of children and families. However, most of the recommendations on
deliberate self harm concern the management of individuals after an episode of self
harm. Across all the countries, despite being a major problem, there are very few
specific proposals to prevent deliberate self harm in policy documents.




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Depression
Depression is the most common of all mental disorders.            It is characterised by
sadness, loss of interest in activities and decreased energy11. It is also associated with
loss of self esteem, feelings of guilt, suicidal thoughts, poor concentration, disturbed
sleep and poor appetite. The severity of depression can range from very mild to very
severe. Although many people experience depressive symptoms following a period of
loss or sadness, depression is diagnosed when symptoms reach a threshold and last for
at least two weeks11.       Australia describes this clinical depression as a group of
illnesses characterised by excessive and long-term lowering of mood which, along
with a range of symptoms, affects the person‟s lifestyle and ability to cope with life89.
Depressive disorders may be classed as unipolar (which is responsible for the greatest
burden of disease) or the much rarer bipolar disorders, in which sufferers experiences
periods of depression and at other times episodes of elated mood or mania. Bipolar
disorder is estimated to affect 1 – 3% of the population.


Depression is responsible for very high levels of morbidity. WHO ranks depressive
disorders as the fourth leading cause of morbidity accounting for 4.4% of the total
DALYs (disability adjusted life years). Further, it predicts that if current trends
continue, by 2020 this burden of disease will increase to 5.7%, making depression the
second leading cause of DALYs lost11. Women are about two times more likely to
suffer from depression than men. Currently, among women aged 15 – 44 years,
depression accounts for 8.6% of DALYs lost.            At the national level therefore
depression is very costly, but at the individual, family and community level,
depression also has a profound effect, both economically and socially. Australia
estimates that the one year adult prevalence rate for depressive disorders is about 6%,
but that the proportion of people that suffer from major depression at some during
their lives is much higher89. England estimates that almost 7% of women and more
than 3% of men will be affected by depression every year25.


Approaches to the treatment of depression in policy documents
The majority of policy documents do not include separate strategies to tackle
depression. England and Australia review the risk factors for depression among older
people36   90
                .   England in its National Service Framework on mental health also



                                           93
reviews the treatment options for depression including medication and other methods
such as cognitive therapy and psychotherapy25. However, it also reports that only
30% to 50% of depression in primary care is recognised by GPs, highlighting scope
for GPs and practice nurses to improve assessment skills and knowledge, skills and
training to give non-drug treatments. Denmark reports that it has published guidelines
for the diagnosis and treatment of depression in primary care (not available in
English)73. Scotland has several initiatives to address depression. For example,
Doing well by people with depression, is an initiative running in seven health board
areas which aims to improve access to appropriate services188. One of the actions
proposed for “improving infant mental health”, is to develop new initiatives aimed at
improving prevention, identification and early treatment for post natal depression.
New Zealand reports the need for better recognition and identification of depression.
Thus it aims to complete a scoping project (by January 2006) on how to increase the
public‟s understanding and awareness of depression.


Depression is often mentioned in suicide strategies. Japan wants to do more to ensure
the early detection and treatment of depression as one of the ways to reduce suicide17.
Scotland‟s suicide prevention strategy is concerned about recognition of depression in
young people and describes Breathing Space, a service which is particularly targeted
at young men suffering from low mood and depression. The aim of this service is to
put people in touch with local appropriate services32.


Australia’s National Action Plan for Depression
Australia is the only country to have a separate policy document on depression. The
National Action Plan for Depression89 was developed in response to the current
problem with depression and the predictions for further increases in the prevalence.
Australia believes that although many effective treatments are available for
depression, a coordinated approach and concerted action is required to tackle the
problem. The overall aim of the Action Plan is to provide national leadership, to
encourage broader implementation of effective programmes and enhance cooperation
between the diverse range of activities already in place. This fostering of cooperation
and partnership between national, state and local services will serve to reduce both the
prevalence of and the impact of depressive disorders. The Action Plan is made up of
two parts: a public mental health promotion and prevention component and a clinical


                                          94
management component.        The health promotion and prevention component is
population based but with special attention to high risk groups (those at high risk of
developing depressive symptoms and those showing early signs and symptoms). The
clinical management component focuses on early detection and management of
depression, ensuring education and training of professionals, and promoting an
evidence based approach to the management of depression.


In addition to identifying areas for action to reduce depression the Action Plan
suggests areas where research is required. A range of topics are suggested from
identifying why individuals are reluctant to seek help for depression, to evaluating the
effectiveness of specific treatments such as brief evidence based medical and
psychological interventions in primary care setting with different patient groups. It
suggests that the relationship between early detection and treatment and clinical
outcome in the short and long term should also be investigated.




                                          95
96
Section 4:

Evaluation




    97
Evaluation
The importance of evaluation of policy is illustrated in the development of policy in
Australia and New Zealand. In both countries rigorous evaluation has determined
where and when changes in the direction of policy were required. For example, in the
late 1990s, New Zealand was concerned about access to mental health services, and
made it a priority. A subsequent evaluation by the Mental Health Commission in
2004, revealed that although access rates for the general population were improving,
access rates for children and young people, and older people fell short of the targets.
Thus it became an area requiring attention in the new policy15.


Australia‟s current Mental Health Plan23 stresses the need to ensure that evaluation is
an integral part of the implementation of the policy. Evaluation of the previous
Mental Health Plans contained a number of components which included a mix of
quantitative data, primarily from mental health reports, and qualitative data, from key
informants and from international experts conducting independent reviews. It reports
that it remains committed to continuous evaluation, including external review.
However, details of how the current policy will be evaluated are not given. The
document states that indicators will be developed from the “broad outcomes described
in the policy, so that success can be monitored”. Australia also stresses the need for
evaluation of specific initiatives that have been introduced, in order to determine what
works and what is ineffective and to aid decisions on what initiatives should be
replicated or developed further.


The USA regularly conducts extensive evaluation of progress towards policy targets.
The final review of Healthy People 2000189 gives progress on the fifteen targets for
mental health. Only five targets were met including: a reduction in the overall suicide
rate, an increase in the use of community services by people with severe mental health
problems, and an increase in the number of adults seeking help with emotional and
personal problems. However, for seven of the targets movement was in the wrong
direction: the number of suicide attempts among adolescents increased, suicide in jails
increased. The number of adults treated for depression decreased but only slightly
and the number of workplaces with stress management programmes also fell slightly.
The USA continually reassesses the evaluation programme and includes


                                          98
developmental targets in policy. Thus Healthy People 201016 has several new mental
health targets including: targets to reduce the relapse rates for persons with eating
disorders including anorexia nervosa and bulimia nervosa; to increase the number of
persons seen in primary health care who are screened for mental health problems; and
to increase the proportion of children with mental health problems who receive
treatment.


Most countries do not provide a summary of the evaluation of previous policy in their
current policy documents.     However, sometimes the data are presented in other
government documents. For example, the recent Chief Medical Officer‟s Report from
Wales104, reported on progress from 1997 to 2002. Two of the fifteen health gain
targets were relevant to mental health: suicide and mental health status as measured
by the Mental Component Score (MCS). Neither of the targets was met. Although
Wales has seen year on year fluctuations in suicide rates, the overall trend is an
increase. The MCS has remained unchanged in Wales for several years.



Indicators
Some countries propose the use of indicators to monitor the impact of policies. A
very extensive report from Finland describes a carefully conducted review of the
literature on mental health and on measuring mental health. It has detailed
psychological models as well as validated approaches to assessing mental health and
mental services40. From this a minimum data set of European mental health indicators
has been proposed190. The list is too long to be described here, but interested readers
may wish to refer to it. However, European countries have not yet adopted a common
set of indicators.


England uses indicators widely in mental health policy.          The National Service
Framework has many indicators and milestones. For example, indicators for severe
mental illness cover prevalence, contact with health care services, independent living
and wellbeing and the wellbeing of carers25. Other countries, such as Scotland are
currently developing indicators191. Northern Ireland, in its consultation document for
the mental health promotion strategy68, identifies the need for indicators of progress,
but points out that these are not readily available. It suggests that indicators could be


                                           99
developed from broader health determinants such as working conditions, social
circumstances and social support and relationships. It identifies potential specific
indicators on service organisation such as access to services, participation in decision
making processes and the existence of appropriate policies. It also lists several
individual level indicators such as knowledge of mental health problems, self esteem,
coping skills and social support.


Australia makes the most extensive use of indicators. The National Action Plan on
Mental Health Promotion and Prevention36, describes both outcome and process
indicators. The six key outcome indicators include a reduction in the prevalence of
mental health problems and symptoms; improved mental health and mental wellbeing;
increased mental health literacy; improved family functioning and parenting skills;
increased social support and community connectedness; and increased investment into
evidence based programmes to promote mental health and prevent and reduce mental
health problems. Eight process measures are described which cover monitoring and
surveillance of mental health problems, the presence of evidence based programmes;
increased early detection of problems and early referral; improved community
education; increased public policy and practice that promote mental health; increased
professional education and training; and increased intersectoral working.          The
Australian framework for the prevention of suicide also identifies many performance
indicators52. Many of these are process measures such as appropriate infrastructure
and the number of intervention programmes delivered. Others are outcome measures
such as prevalence of depression, decreased sexual abuse of children, substance
abuse.




                                          100
 Section 5:

Commentary




     101
Commentary
This review of international public mental health has revealed that all the countries
studied have extensive documentation on public mental health policy. In part this
reflects the scale and variety of mental health problems, but it may also signal a
general acceptance of the frequently quoted phrase “there is no health without mental
health”. This phrase echoes the definition of health in the 1946 Constitution of World
Health Organisation which refers to physical, mental, and social wellbeing. All
countries recognise the need for an effective policy on mental health and are
committed to developing one.


Aspects of mental health policy can appear in many different types of documents
including: general public health documents; mental health care documents; public
mental health documents; separate strategy documents for specific population group
(eg children, older people or prisoners); documents on mental health promotion; and
documents on specific topic (eg suicide or stigma). There are considerable differences
between countries in the types of documents and the ways in which topics are
covered. A challenge for each country is to coordinate across the many policy
recommendation to ensure a consistent approach. The danger is that different
priorities are set for a topic in say a health care policy compared to a mental health
promotion policy or a suicide policy.


Deinstitutionalisation
The dominant event in mental health policy in the 20th Century was the
deinstitutionalisation of mental health services. Many countries found it difficult to
provide appropriate community-based services when the major psychiatric hospitals
were closed. There is now general acknowledgement that the resources to implement
the transition were inadequate. Although increased investment has occurred in mental
health, almost all countries report that public mental health requires still more
resources. The question thus arises of why there has been long term underfunding of
mental health in so many countries. One possibility is that the stigma which attaches
to mental illness somehow exerts a subtle influence on those who make decisions on
funding. Another possibility is that because it can be chronic and debilitating, mental
illness is given less attention than acute high mortality diseases such as heart disease


                                          102
and cancer. It is to be hoped that the current emphasis on the human rights of those
with mental health problems may help to redress this problem. The statements of the
principles on which policy should be based are encouraging signs that mental health
may be given priority appropriate to the scale of the public health problems that it
presents.


Scale of the problem
Mental health problems are a major contributor to the global burden of disease. WHO
predicts that by 2020, if current trends continue, depression will become the second
leading cause of DALYs (disability adjusted life years) lost11. Most countries give
estimates of the overall burden of mental health problems. However the terms mental
health problems, mental disorders and mental illnesses are used in different ways
across the countries and also across documents within countries. Thus, although all
agree the problem is large, the lack of comparable data makes it difficult to be sure
how large.


There is little information on the prevalence of the common mental health problems
such as depression, schizophrenia or eating disorders. The exception is suicide where
data are available from all countries. The lack of information on the other disorders
makes it difficult to assign a priority to each, or to identify whether the resources
given to it are appropriate to the scale of the problem. There are also very few
estimates of the costs to society of mental health problems. From the limited data
presented it is clear that the costs are substantial, involving not just health and social
care costs, but also those due to loss of employment opportunities. It is possible that
mental health might be given a higher priority if the true costs to society were more
widely discussed.


Causes of mental health problems
Most countries discuss the causes of mental health problems. However, the focus is
generally on the determinants of overall mental wellbeing and mental ill health.
There is some variation in the way countries conceptualise mental health and mental
ill health, although the determinants are seen as the combination and/or interaction of
psychological, social and physical factors, which operate at different levels
throughout the lifecourse. All countries recognise the complexity of causation, and in


                                           103
particular the contribution of the wider determinants of mental health problems.
Although these determinants lie outside the remit of health care, almost all the
policies     emanate   solely from    Ministries   of   Health.   The    policies   make
recommendations which would have major implications for other government
departments and other groups in society. Often lists of the relevant departments and
organisations are presented in policy documents. Unfortunately it is not clear that
these other agencies are fully committed to the proposals in policy. Further there is
seldom mention of mechanisms to bring the stakeholders together, or of the provision
of the resources which would be required to deliver the proposed interventions.


What is generally missing from policy is a review of the causes of specific conditions
such as depression, deliberate self harm or eating disorders. Although there may be
some common factors for the different disorders, it is surprising that little attention is
given to the determinants of individual disorders. In fairness, public mental health
policy would have to be very long and detailed if the aetiology and epidemiology of
individual disorders were discussed. Yet in the absence of such detail it is difficult to
design appropriate interventions to tackle the underlying causes of the individual
disorders.


Goals
Most countries set comprehensive goals: to improve general mental well-being; to
improve mental health services; to reduce the prevalence of mental health disorders;
and to reduce the impact of mental health problems. Thus there is substantial
emphasis on mental health promotion, service delivery and tackling stigma. However
few countries have set targets for the desired improvements on each of the goals.
Indeed there are few numerical targets across all the countries and those presented
differ between countries.


Policy development
Many parts of policy are in an active state of development and are more concerned
with identifying the important issues rather than providing targeted actions to resolve
them. Even Australia and New Zealand, who have the longest standing and most well
developed public mental health policy, identify the need for further policy
development. Thus the development of policy is expressed as a key function of


                                           104
policy. Given the relative recency of public mental health policy, it is important that
the appropriate infrastructure be developed before detailed strategies for
implementation can be put into place. This means that improvements in mental health
outcomes will only be achieved in the longer term.


Mental health promotion
Mental health promotion is the major thrust of public mental health policy, and high
expectations are placed on it. This is seen in the broad aims which are set for mental
health promotion. These are to improve mental wellbeing, reduce the incidence and
impact of mental health disorders and assist in recovery from mental health problems.
Thus they address the same issues as the overarching goals of public mental health
policy. The remit is challenging, particularly as many of the determinants of mental
health problems lie outside the ambit of health care. Action is usually proposed at
three levels: individual; community; and macro level (which tackles the wider
determinants).    Many of the desired outcomes will be difficult to achieve.        For
example, at the individual level, mental health promotion sets out to strengthen
individuals by increasing their resilience and ability to cope with adverse events. At
community level, “fostering supportive environments” may be seen as a way of
improving general mental health. These interventions either involve direct contact
with large numbers of individuals or considerable investment to improve the physical,
social and economic environments. These issues are alluded to, rather than addressed,
in policy.


Specific groups
In addition to general strategies to improve mental wellbeing, all countries identify
groups within society whose needs require special attention. The most commonly
identified groups are children, older people and carers. These groups are clearly
deserving of attention, but they also share the common feature of the potential for cost
to society. Children are important because of the serious long term consequences of
poor mental health. The conditions which older people most commonly experience,
such as dementia, require considerable long term resource. The ageing of the
population increases the importance of this issue. Finally, the contribution of carers
saves a potentially substantial input from health care services.



                                          105
The other groups who are singled out are those who have needs which are unlikely to
be addressed through general approaches. Thus there is mention of prisoners, certain
ethnic groups, recent immigrants, homeless and socially disadvantaged people as well
as those with learning difficulties and those with addiction problems. Unfortunately
proposals to tackle mental health problems in these groups are inconsistently
discussed across countries. There are some notable policy documents, such as
Australia‟s implementation plan for multicultural groups and England‟s policy on
social exclusion, but these are rare. Clearly it would be extremely challenging to
produce policy proposals for every mental health problem for all special groups. Yet
in not doing so, many serious mental health problems may be unaddressed. This is yet
another illustration of the scale of the challenge posed by mental health.


Stigma
Stigma has long been associated with mental illness and all countries address this in
policy. However the nature and causes of stigma are not well explored, which could
make it difficult to tackle the underlying causes of the problem. One difficulty is that
stigma can present in different ways in different situations. For example, it may
present as fear of violence in some people, while others may suffer embarrassment
from being unable to communicate with a person suffering from a mental health
problem.


The most common approach to tackling stigma is to raise awareness on mental health
problems. However, it is recognised that this is not enough. The Surgeon General, in
1999, acknowledged that the USA had assumed that stigma would be eliminated
when the general public had increased knowledge on mental health and that this has
not occurred47. New Zealand also recognised that the problem is complex and stated
that “we need to be on guard against simple solutions”110.          Its current strategy
therefore places more emphasis on the much more difficult task of changing people‟s
behaviour to counter discrimination in many areas, such as in gaining access to
employment and education.


Suicide, depression and deliberate self harm
Policy on suicide is particularly well developed, with several countries having
separate policy documents to address it. In contrast to policies on other aspects of


                                          106
mental health, policies on suicide typically review the scale of the problem and the
main risk factors as well as those groups at particular risk of suicide. Further a much
wider range of interventions is proposed, which are often described in more detail,
than for other topics. In part the interest in suicide may reflect the extensive
epidemiological research which has been conducted on suicide. This may reflect the
primacy of death over morbidity.


Despite being a common problem depression receives little attention in policy.
Australia is the only country to have a stand alone policy on depression, which it
developed in response to the high levels of depression and the predicted increase in
depressive disorders. We were unable to find any policies devoted to deliberate self
harm. This topic is mentioned in several suicide policies, but often it is identified as a
risk factor for suicide rather than a problem deserving attention in its own right. It is
interesting to contrast the attention given to suicide particularly with that given to
deliberate self harm and depression. The societal costs of these two conditions far
outweigh that of suicide, yet they are given scant attention in most countries‟ policies.




Non-governmental organisations
Many countries recognise the substantial contribution that non-governmental
organisations make to mental health, covering a wide range of services such as
supported housing, drop-in centres, self help and self management, advocacy and
welfare rights advice. There is also recognition that the role of NGOs could be
expanded, although their funding would need to be made more secure. Few policies
explore the practicalities of integrating the work of the statutory and voluntary
sectors, although England is notable in establishing a national programme to promote
partnership and to strengthen the links between government and the voluntary sector.
One other challenge to be addressed is accountability and governance. This is well
developed within healthcare systems, which have sufficient resources to devote to it.
This may be more difficult for voluntary organisations, many of which are small and
have limited resources.




                                           107
Implementation
Delivering the interventions outlined in policy documents may often pose serious
challenges. Many of the proposals for interventions could have substantial resource
implications. For example national parenting programmes or programmes to improve
life skills and coping skills among young people would involve repeated contact with
a large proportion of the population. The issues of providing sufficient trained staff to
provide these programmes and the financing of such are not discussed. Some
interventions, particularly those involving high risk groups, may be difficult to
deliver. For example older people at high risk of depression include those who have
experienced bereavement, retirement, chronic physical health problems or social
isolation. Identifying these individuals can be difficult and contacting them may raise
ethical problems about the reason they are being approached. The recognition of the
wider determinants of health leads to recommendations for interventions which will
affect a wide range of individuals. These include the judicial services, journalists and
newspaper editors, staff in all levels of education, community workers, general health
care and social care. Enlisting the active participation of professional groups who may
not have mental health as a priority could be difficult. The challenges are whether
these stakeholders will have sufficient time and resources and how they will be given
adequate training to be able to deliver the interventions. It is unfortunate that the
challenges in delivering the proposed interventions are not resolved within policy
documents.


Evaluation
In most countries public mental health policies are relatively recent so there has been
limited opportunity for evaluation. However, progress to reducing the problem of
stigma has been evaluated in several countries, and all countries have data on trends
in suicide. There may still be some delay in conducting evaluation of other aspects of
policy as many countries are at the stage of developing suitable indicators. This means
that baseline data has yet to be collected. New Zealand and Australia are notable
exceptions, as they have rigorously evaluated policy and used the results to improve
subsequent policies.




                                          108
Research
The need for further research is widely recognised. Commonly the interest is to
develop effective interventions to tackle mental health problems. But many countries
also recognise that before this can be done, a better understanding is needed of the
factors contributing to mental illness. To achieve this will require increased funding
and an increase in the number of experienced mental health researchers. The way in
which this will be achieved is not discussed in policy.


Conclusion
Mental health is addressed in many policy documents in most countries, many of
which have been published recently. It is clear from policy documents that mental
health represents a vast and varied set of topics. The need for further policy
development is recognised, particularly to establish the infrastructure to oversee and
ensure the delivery of effective interventions. Less recognised is the need for more
attention to the current Cinderella topics of depression and deliberate self harm. The
needs of specific groups in society, such as the socially disadvantaged, ethnic
minorities and prisoners, could be treated more systematically across the range of
mental health problems.


Mental health policy faces a number of challenges. Mental health problems are
common, highly varied in nature, and have a complex set of causes. Thus tackling
them requires a wide ranging set of interventions which need to be delivered by
professional groups and key individuals from all sectors of society. Ensuring that
mental health is a priority for all these stakeholders is an issue still to be resolved. The
common and continuing problem of stigma exacerbates mental health problems and
impedes the delivery of the mental health agenda. Finally, increased investment in
mental health services will be required to ensure that current needs are adequately
met. It is to be hoped that the current prominence of human rights in mental health
policy will lead to increased activity in all sectors to confront the problems posed by
mental health.




                                           109
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     Institute (KTL) Ministry of Social Affairs, 1999.

79   Department of Mental Health and Substance Dependence. Investing in Mental Health.
     Geneva: WHO, 2003. http://www.who.int/mental_health/media/en/investing_mnh.pdf

80   (mhGAP) mhGAP. Close the Gap, Dare to Care. Geneva: WHO, 2002.
     http://www.who.int/mental_health/media/en/265.pdf

81   WHO European Ministerial Conference on Mental Health. Mental Health in Europe:
     Facing the Challenges, Building Solutions: Briefing Papers. Helsinki: WHO, 2005.
     http://www.euro.who.int/mentalhealth2005/ineurope/20041123_1

82   WHO. Investing in Mental Health. Geneva: WHO, 2003.
     http://www.who.int/mental_health/en/investing_in_mnh_final.pdf

83   Gabriel P, Liimatainen M. Mental Health in the workplace. Introduction and executive
     summaries. Geneva: International Labour Office, 2000.
     http://www.ilo.org/public/english/employment/skills/disability/download/execsums.pdf

84   National electronic Library for mental health, 2005. http://www.nelmh.org/..

85   Public Health Institute of Scotland. Needs Assessment Report on Child and Adolescent
     Mental Health. Final Report - May 2003. Edinburgh: Scottish Executive, 2003.
     http://www.phis.org.uk/pdf.pl?file=pdf/CAMH1.pdf

86   Women and Children's Unit, Health Department. Children and Young People's Mental
     Health: A Framework for Promotion, Prevention and Care. Edinburgh: Scottish
     Executive, 2004. http://www.scotland.gov.uk/consultations/health/cypmh.pdf

87   Department of Health. National Service Framework for Children, Young People and
     Maternity Services. Executive Summary. London: UK Parliament, 2004.
     http://www.dh.gov.uk/assetRoot/04/09/05/52/04090552.pdf

88   Department of Health. The Mental Health and Psychological Well-being of Children
     and Young People. London: UK Parliament, 2004.
     http://www.dh.gov.uk/assetRoot/04/09/05/60/04090560.pdf

89   Commonwealth Department of Health and Aged Care. National Action Plan for
     Depression. Canberra: Mental Health and Special Programs Branch, 2000.
     http://www.mentalhealth.gov.au/resources/pdf/depression.pdf


                                            115
90   Department of Health. National Service Framework for Older People. London: UK
     Parliament, 2001. http://www.doh.gov.uk/nsf/pdfs/nsfolderpeople.pdf

91   Home Office. Caring about Carers: National Strategy for Carers. London: UK
     Parliament England, 1999. http://www.carers.gov.uk/pdfs/Care.pdf

92   Department of Health. Delivering Choosing Health: making healthier choices easier.
     London: UK Government, 2005.
     http://www.dh.gov.uk/assetRoot/04/10/57/13/04105713.pdf

93   Commonwealth Department of Health and Aged Care. National Framework for
     Implementation of the National Mental Health Plan 2003-2008 in Multicultural
     Australia, 2004. http://www.mmha.org.au/Policy/framework.pdf

94   Prison Health Policy Unit and Task Force. Changing the Outlook. A strategy for
     developing and modernising mental health services in prisons. London: Department of
     Health and HM Prison Service, 2001.
     http://www.dh.gov.uk/assetRoot/04/03/42/28/04034228.pdf

95   Prison Health Policy Unit and Task Force. Health Promoting Prisons: a shared
     approach. London: Department of Health and HM Prison Service, 2002.
     http://www.dh.gov.uk/assetRoot/04/03/42/65/04034265.pdf

96   Department of Mental Health and Substance Dependence. The Role of International
     Human Rights in National Mental Health Legislation. Geneva: WHO, 2004.
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     glish_r1.pdf

97   WHO. Mental Health Legislation & Human Rights. Geneva: WHO, 2003.
     http://www.who.int/mental_health/resources/en/Legislation.pdf

98   World Health Organisation. WHO Resource Book on Mental Health, Human Rights
     and Legislation. Stop exclusion, dare to care. Geneva: WHO, 2005. http://www.ruig-
     gian.org/proj/WHOResourceBook050210.pdf

99   WHO European Ministerial Conference on Mental Health. Mental Health Declaration
     for Europe. Facing the Challenges, Building Solutions. Helsinki: WHO, 2005.
     http://www.euro.who.int/document/mnh/edoc06.pdf

100 WHO. Advocacy for Mental Health. Geneva: WHO, 2003.
    http://www.who.int/mental_health/resources/en/Advocacy.pdf

101 Ministry of Health. Looking Forward. Strategic Directions for the Mental Health
    Services. Wellington: New Zealand Government, 1994.
    http://www.moh.govt.nz/moh.nsf/49ba80c00757b8804c256673001d47d0/05e396f8251
    1ac98cc256c39000857fb/$FILE/looking-forward.pdf

102 Department of Health and Children. Quality and Fairness. A Health System for You.
    Dublin: Government of Ireland, 2001. http://www.doh.ie/publications/strategy.html

103 WHO. Health 21. The health for all policy framework for the WHO European Region.
    Copenhagen: WHO, 1999.

104 Chief Medical Officer. Health Status Wales 2004-2005. Cardiff: Welsh Assembly,
    2005. http://www.cmo.wales.gov.uk/content/publications/reports/health-status-wales-
    e.pdf




                                          116
105 Australian Health Ministers. National Mental Health Policy. Canberra: Australian
    Government, 1992.
    http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/mentalhealth-mhinfo-
    standards-nmhp.htm/$FILE/nmhp.pdf

106 National Mental Health Strategy Evaluation Steering Committee for the Australian
    Health Ministers Advisory Council. Evaluation of the National Mental Health Strategy:
    Final Report: Mental Health Branch, Commonwealth Department of Health and Family
    Services, 1997. http://www.mmha.org.au/Policy/EvaluationNMHPlan

107 Australian Health Ministers. Second National Mental Health Plan. Canberra:
    Commonwealth Department of Health and Family Services, 1998.
    http://www.health.gov.au/hsdd/mentalhe/mhinfo/nmhs/plan2.htm

108 Betts V, Thornicroft G. International Mid-Term Review of the Second National Mental
    Health Plan for Australia. Canberra: Mental Health and Sprecial Programs Branch,
    Department of Health and Ageing, 2002.
    http://www7.health.gov.au/hsdd/mentalhe/mhinfo/nmhs/pdf/review.pdf

109 Steering Committee for the Evaluation of the Second National Mental Health Plan
    1998-2003. Evaluation of the Second National Mental Health Plan. Canberra:
    Commonwealth of Australia, 2003.
    http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-mhinfo-
    nmhs-evaluation.htm/$FILE/eval.pdf

110 Mental Health Commission. Blueprint for Mental Health Services in New Zealand.
    How Things Need To Be. Wellington: MHC, 1998.
    http://www.mhc.govt.nz/publications/1998/Blueprint1998.pdf

111 Ministry of Health. New Futures. A strategic framework for specialist mental health
    services for children and young people in New Zealand. Wellington: New Zealand
    Government, 1998. http://www.moh.govt.nz/moh.nsf/Files/newftres/$file/newftres.pdf

112 Mental Health Commission. Mental Health Commission Strategic Plan 2001-2004.
    Building on the Blueprint. Wellington: New Zealand government, 2001.
    http://www.mhc.govt.nz/publications/2001/C.pdf

113 Ministry of Health. DHB Toolkit. Mental Health. Wellington: New Zealand
    Government, 2001. http://www.newhealth.govt.nz/toolkits/mentalhealth.htm

114 Ministry of Health. DHB Toolkit. Minimising Alcohol and Other Drug Related Harm.
    Wellington: New Zealand Government, 2001.
    http://www.newhealth.govt.nz/toolkits/alcohol/AlcoholandDrugs.pdf

115 Ministry of Health. Building on Strengths: A Springboard for Action. Wellington: New
    Zealand government, 2001.
    http://www.moh.govt.nz/moh.nsf/0/b9b5016469ad25b3cc256a8f000a1abc/$FILE/Sprin
    gboardDocument.pdf

116 Akroyd S, Wyllie A. Impacts of National Media Campaigns to Counter Stigma and
    Discrimination Associated with Mental Illness: Survey 4. Phoenix Research: Ministry
    of Health, 2002.
    http://www.likeminds.govt.nz/Documents/Phoenix%20reports/R3250CJan03v6.pdf




                                          117
117 Associate Minister of Health. A Life Worth Living: New Zealand Suicide Prevention
    Strategy: Consultation document. Wellington: Ministry of Health and Ministry of
    Youth Development, 2005.
    http://www.moh.govt.nz/moh.nsf/0/AC2DD0C557C226BBCC256FF00004A418/$File/
    suicidepreventionstrategy.pdf

118 WHO European Ministerial Conference on Mental Health. Mental Health Action Plan
    for Europe. Facing the Challenges, Building Solutions. Helsinki: WHO, 2005.
    http://www.euro.who.int/document/mnh/edoc07.pdf

119 Joubert N, Raeburn J. Mental Health Promotion: People, Power and Passion.
    International Journal of Mental Health Promotion 1998;Inaugural Issue:15-22.

120 Liimatainen M. Mental Health in the workplace: situation analysis, Finland. Geneva:
    International Labour Office, 2000.
    http://www.ilo.org/public/english/employment/skills/disability/papers/fincover/index.ht
    m

121 Department of Health. Choosing Health: Making healthy choices easier. London: UK
    Parliament, 2004.
    http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndG
    uidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4094550&chk=
    aN5Cor

122 The Carter Center Mental Health Program. The Rosalynn Carter Fellowships for
    Mental Health Journalism. Atlanta, 2004.
    http://www.cartercenter.org/documents/nondatabase/0506FellowsBrochure.pdf

123 Mrazek P, Haggerty R. Reducing Risks for Mental Disorder: Frontiers for Preventive
    Intervention Research. Washington, DC: Institute of Medicine, 1994.

124 Crombie I, Irvine L, Elliott L, Wallace H. Understanding Public Health Policy.
    Learning from International Comparisons: Public Health in Scotland (PHIS), 2003.
    http://www.phis.org.uk/projects/network.asp?p=fh

125 Crombie I, Irvine L, Elliott L, Wallace H. Closing the Health Inequalities Gap: An
    International Perspective: WHO/NHS Health Scotland, 2005 in press.

126 Department of Health. Tackling Health Inequalities. A Programme for Action. London:
    UK Government, 2003. http://doh.gov.uk/healthinequalities/programmeforaction

127 Department of Health. Modernising Mental Health Services. Safe, sound and
    supportive. London: UK Parliament, 1998.
    http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndG
    uidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4003105&chk=
    psls3f

128 Welsh Assembly Government. Adult Mental Health Services. A National Framework
    for Wales. Cardiff, 2002.
    http://www.wales.nhs.uk/sites/documents/438/adult%2Dmental%2Dnsf%2De%2Epdf

129 McCulloch A, Glover G, St John T. The National Service Framework for Mental
    Health: Past, Present and Future. The Mental Health Review 2003;8:7-17.

130 Ministry of Health. Mental Health (Alcohol and Other Drugs) Workforce Development
    Framework. Wellington: New Zealand Government, 2002.
    http://www.moh.govt.nz/moh.nsf/0/a9394a53038a5061cc256c4c007187ce/$FILE/Ment
    alHealthWorkforceDevelopmentFramework.pdf


                                           118
131 Ministry of Children and Family Affairs. National Report on Youth Policy in Norway.
    Olso: Norwegian Government, 2003.
    http://odin.dep.no/filarkiv/197907/NationalYouthReports.pdf

132 Department of Health and Children. The National Children's Strategy: Our Children -
    Their Lives. Dublin, 2000. http://www.doh.ie/pdfdocs/childstrat_report.pdf

133 Ministry of Health. Better Times. Contributing to the Mental Health of Children and
    Young People. Wellington: NZ Government, 1999.
    http://www.moh.govt.nz/moh.nsf/0/357db0e1610bcff5cc256b9c007faef8/$FILE/bettert
    imes.pdf

134 Department of Health and Human Services. Report of the Surgeon General's
    Conference on Children's Mental Health: A National Action Agenda. Washington, DC:
    US Government, 2000. http://www.hhs.gov/surgeongeneral/topics/cmh/cmhreport.pdf

135 Expert Group on Healthcare of Older People. Adding Life to Years. Edinburgh:
    Scottish Executive, 2002. http://www.scotland.gov.uk/library3/health/alty.pdf

136 NHS Health Scotland. Dementia and Older People. Edinburgh: NHS Health Scotland,
    2003. http://www.phis.org.uk/pdf.pl?file=publications/dementia%20HNA.pdf

137 Gow J, Gilhooly M. Risk Factors for Dementia and Cognitive Decline. Edinburgh:
    NHS Health Scotland, 2003.
    http://www.phis.org.uk/pdf.pl?file=publications/dementia%20LR.pdf

138 De Leo D, Hickey P, Neulinger K, Cantor C. Ageing and Suicide. Canberra:
    Commonwealth of Australia, 2001.
    http://www.gu.edu.au/school/psy/aisrap/pdf/ageing.pdf

139 Minister for Health and Social Services. A Healthier Future for Wales. Cardiff: Welsh
    National Assembly, 2000.
    http://www.wales.gov.uk/subihealth/content/keypubs/healthfut/fut.pdf

140 Department of Health Social Services and Public Safety. Informal Carers Report.
    Belfast: Northern Ireland Assembly, 2001.
    http://www.dhsspsni.gov.uk/publications/archived/2001/informal_carers_report.pdf

141 Ministry for Health Social Services and Public Safety. Valuing Carers. Belfast:
    Northern Ireland Assembly, 2002.
    http://www.dhsspsni.gov.uk/publications/2002/valuing_carers.pdf

142 The Royal College of Psychiatrists. Partners in care. 2005.
    http://www.rcpsych.ac.uk/campaigns/pinc/launch.htm

143 Carers Northern Ireland. http://www.carers.ni.org. 2005.

144 Carers Scotland. http://www.carerscotland.org. 2005.

145 Carers Wales. http://www.carerswales.org. 2005.

146 Caring for Carers Inc. http://www.caringforcarers.org.nz/. 2005.

147 National Mental Health Association (NMHA). http://www.nmha.org/. USA, 2005.

148 Mental Health Ireland. http://www.mentalhealthireland.ie/default.asp. 2005.

149 Schizophrenia Society of Canada. http://www.schizophrenia.ca/. 2005.




                                           119
150 Robert Mond Memorial Trust. Stigma.org. USA, 2005. http://www.stigma.org/

151 Depression Alliance. http://www.depressionalliance.org/. UK, 2005.

152 Platform, Support Services and Community Development in Mental Health. Advocacy
    and Lobbying Guidelines. New Zealand, 2005.
    http://www.platform.org.nz/links/platform_1_1.php

153 National Stigma Clearinghouse.USA, 2005.http://community-2.webtv.net/stigmanet

154 European Information Desk on Mental Illness. 2005. http://www.eufami.org/en/

155 World Federation for Mental Health.2005.http://www.wfmh.org/

156 Department of Health and Children. Working for health and well-being. Dublin: Irish
    Government, 1997. http://www.doh.ie/publications/sos98.html

157 Home Office, Active Community Unit. Strengthening Partnerships: Next Steps for
    Compact. The Relationship between the Government and the Voluntary and
    Community Sector. London, 2005.
    http://www.homeoffice.gov.uk/docs4/Compact_61pp_web.pdf

158 Home Office, Active Community Unit. Developing Capacity: Next Steps for
    ChangeUp. Developing Excellence in the Voluntary and Community Sector. London,
    2005. http://eastmidlandsinfrastructure.org.uk/documents/DevelopingCapacity-
    NextStepsForChangeup.pdf

159 Home Office. ChangeUp. Capacity Building and Infrastructure Framework for the
    Voluntary and Community Sector: UK Parliament, 2004.
    http://www.bvsc.org/files/downloads/pdf/changeup_report_new.pdf

160 Like Minds Like Mine. Orientation Kit: Ministry of Health, 2004.
    http://www.likeminds.govt.nz/Documents/orientation_kit.pdf

161 Mental Health Commission. Journeys Towards Equality. Wellington, 2004.
    http://www.mhc.govt.nz/publications/2004/MHC_Journeys_5.pdf

162 The Irish Division of the Royal College of Psychiatrists. The Changing Minds
    Campaign. 1999. http://www.irishpsychiatry.com/survey.html

163 Canadian Mental Health Association. The 2001 Canadian Mental Health Survey, 2001.
    http://www.cmha.ca/english/research/compas_survey.htm

164 National Statistics. Attitudes to Mental Illness 2003. London: Department of Health,
    2003. http://www.nimhe.org.uk/downloads/mentalillnessreport.pdf

165 Braunholtz S, Davidson S, King S, Scotland M. Well? What do you think?. The
    Second National Scottish Survey of Public Attitudes to Mental Health, Mental Well-
    being and Mental Health Problems. Edinburgh: Scottish Executive Social Research,
    2004. http://www.scotland.gov.uk/library5/health/pamhs.pdf

166 Minister for Disability Issues. The New Zealand Disability Strategy. Making a World
    of Difference. Wellington: Ministry of Social Development, 2001.
    http://www.odi.govt.nz/documents/publications/nz-disability-strategy.pdf

167 The Royal College of Psychiatrists. Changing Minds. 2005.
    http://www.rcpsych.ac.uk/campaigns/cminds/index.htm




                                           120
168 National Institute for Mental Health in England. Scoping review on Mental Health Anti
    Stigma and Discrimination - Current Activities and What Works. London: Department
    of Health, 2004.
    http://www.londondevelopmentcentre.org/resource/local/docs/AntiStigma.pdf

169 "See Me" Scotland. 2005. http://www.seemescotland.org/

170 Resource Center to Address Discrimination and Stigma. US Department of Health and
    Human Services, 2005. http://www.adscenter.org/

171 sane Australia. StigmaWatch. 2005.
    http://www.sane.org/index.php?option=displaypage&Itemid=266&op=page

172 Crisp A, Gelder M, Rix S, Meltzer H, Rowlands O. Stigmatisation of people with
    mental illnesses. British Journal of Psychiatry 2000;177:4-7.

173 Ministry of Health. National Plan 2003-2005. Project to Counter Stigma and
    Discrimination Associated with Mental Illness. Wellington: New Zealand government,
    2003.
    http://www.moh.govt.nz/moh.nsf/0/0b3625f33ef8c2d6cc256e35000a1e5b/$FILE/Natio
    nalPlan2003-05.pdf

174 Canadian Association for Suicide Prevention. Blueprint for a Canadian National
    Suicide Prevention Strategy. Edmonton, 2004.
    http://www.thesupportnetwork.com/CASP/blueprintE.pdf

175 WHO. http://www.who.int/mental_health/prevention/suicide/country_reports/en/.
    Geneva: web site, 2004.

176 Ministry for Health and Community Care. National Framework for the Prevention of
    Suicide and Deliberate Self-harm in Scotland. Edinburgh: Scottish Executive, 2001.
    http://www.show.scot.nhs.uk/sehd/publications/suicide/suicide%20consultation.PDF

177 Collings S, Beautrais A. Suicide Prevention in New Zealand: A contemporary
    perspective. Wellington: Ministry of Health, 2005.
    http://www.moh.govt.nz/moh.nsf/0/06E426CB2D56854BCC256FFF00170256/$File/su
    icideprevention-socialexplanations.doc

178 Soras I. The Norwegian Plan for Suicide Prevention 1994-1999: Evaluation Findings.
    The Suicide Research and Prevention Unit: University of Oslo, 2000.
    http://www.med.uio.no/ipsy/ssff/engelsk/Soeraas.htm

179 Upanne M, Hakanen J, Rautava M. Can Suicide Be Prevented? The Suicide Project in
    Finland 1992-1996: Goals, Implementation and Evaluation. Helsinki: STAKES, 1999.
    http://www.stakes.fi/verkkojulk/pdf/mu161.pdf

180 US Department of Health and Human Services. National Strategy for Suicide
    Prevention: Goals and Objectives for Action. Rockville, MD: US Government, 2001.
    http://media.shs.net/ken/pdf/SMA01-3517/SMA01-3517.pdf

181 WHO. Formulating strategies for health for all by the year 2000. Geneva: WHO, 1979.

182 Scottish Executive. Social Justice. A Scotland where everyone matters. Edinburgh:
    Scottish Parliament, 1999. http://www.scotland.gov.uk/library2/doc07/sjmd.pdf

183 Measuring Inequalities in Health Working Group. Inequalities in Health. Edinburgh:
    Scottish Parliament, 2003. http://www.scotland.gov.uk/library5/health/hirnov03.pdf




                                          121
184 Department of Health and Children. Report of the National Task Force on Suicide.
    Dublin: The Stationery Office, 1998.

185 Ministry of Health. Suicide and the media. Wellington: New Zealand Government,
    1999.
    http://www.moh.govt.nz/moh.nsf/0/A72DCD5037CFE4C3CC256BB5000341E9/$File/
    suicideandthemedia.pdf

186 Bille-Brahe U. Suicidal Behaviour in Europe. The situation in the 1990s. Copenhagen:
    WHO Europe, 1998. http://www.euro.who.int/document/E60709.pdf

187 Auditor General. Life Matters: Management of Deliberate Self-Harm in Young People:
    The Government of Western Australia, 2001.
    http://www.audit.wa.gov.au/reports/report2001_11.pdf

188 Scottish Executive. National Programme for Improving Mental Health and Well-Being.
    Annual Review 2003-2004. Edinburgh: Scottish Executive, 2004.
    http://www.scotland.gov.uk/library5/health/imhar.pdf

189 US Department of Health and Human Services. Healthy People 2000 Final Review.
    Hyattsville, Maryland: Public Health Service, 2001.
    http://www.cdc.gov/nchs/data/hp2000/hp2k01.pdf

190 STAKES. Minimum data set of European mental health indicators: European
    Commission, 2001. http://www.stakes.fi/mentalhealth/seminar/pdf/indicators.pdf

191 Parkinson J. Indicators of Mental Health and Well-being - Background Paper.
    Edinburgh: NHS Health Scotland, 2004.
    http://www.phis.org.uk/doc.pl?file=pdf/Mental%20Health%20background%20paper%2
    0revised2.doc




                                          122
Appendix 1: Documents used to inform the study
(compiled in date order, most recent first)


Australia
1    Mental Health Branch. National Project Summaries in Mental Health Promotion and
     Suicide Prevention. Canberra: Australian Commonwealth Department of Health and
     Family Services, 2004.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-sp-nsps-
     projects.htm/$FILE/projects0404.pdf
2    Commonwealth Department of Health and Aged Care. National Framework for
     Implementation of the National Mental Health Plan 2003-2008 in Multicultural
     Australia, 2004. http://www.mmha.org.au/Policy/framework.pdf
3    Steering Committee for the Evaluation of the Second National Mental Health Plan
     1998-2003. Evaluation of the Second National Mental Health Plan. Canberra:
     Commonwealth of Australia, 2003.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-mhinfo-
     nmhs-evaluation.htm/$FILE/eval.pdf
4    Department of Health and Ageing. National Mental Health Report 2004: Eighth Report
     - summary of changes in Australia's Mental Health Services under the National Mental
     Health Strategy 1993-2002. Canberra: Commonwealth of Australia, 2003.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pq-mental-
     pubs.htm/$File/NMHR2004_Final_Internet_Release.pdf
5    Australian Health Ministers. National Mental Health Plan 2003-2008. Canberra:
     Australian Government, 2003.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-mhinfo-
     nmhs-2003.htm/$FILE/mhplan.pdf
6    Department of Health and Ageing. National Mental Health Report 2002: Seventh report
     - Changes in Australia's Mental Health Services under the first two years of the Second
     National Mental Health Plan 1998-2000. Canberra: Commonwealth of Australia, 2002.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-
     resources-reports-nmhrep2002.htm/$FILE/fullreport.pdf
7    Betts V, Thornicroft G. International Mid-Term Review of the Second National Mental
     Health Plan for Australia. Canberra: Mental Health and Sprecial Programs Branch,
     Department of Health and Ageing, 2002.
     http://www7.health.gov.au/hsdd/mentalhe/mhinfo/nmhs/pdf/review.pdf
8    De Leo D, Hickey P, Neulinger K, Cantor C. Ageing and Suicide. Canberra:
     Commonwealth of Australia, 2001.
     http://www.gu.edu.au/school/psy/aisrap/pdf/ageing.pdf
9    Auditor General. Life Matters: Management of Deliberate Self-Harm in Young People:
     The Government of Western Australia, 2001.
     http://www.audit.wa.gov.au/reports/report2001_11.pdf
10   Sawyer M, Arney F, Baghurst P, Clark J, Graetz B, Kosky R, et al. Mental Health of
     Young People in Australia. national mental health strategy: Commonwealth
     Department of Health and Aged Care, 2000.
     http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/mentalhealth-
     resources-young-index.htm/$FILE/young.pdf



                                           123
11   Department of Health and Aged Care. LIFE. A framework for prevention of suicide and
     self-harm in Australia. Building partnerships. Canberra: Commonwealth of Australia,
     2000. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-
     resources-life-building.htm/$FILE/building.pdf
12   Department of Health and Aged Care. LIFE. A framework for prevention of suicide and
     self-harm in Australia. Learnings about suicide. Canberra: Commonwealth of
     Australia, 2000.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-
     resources-life-learning.htm/$FILE/learning.pdf
13   Department of Health and Aged Care. LIFE. A framework for prevention of suicide
     and self-harm in Australia. Areas for action. Canberra: Commonwealth of Australia,
     2000. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-
     resources-life-action.htm/$FILE/action.pdf
14   Commonwealth Department of Health and Aged Care. National Mental Health Report
     2000: Sixth Annual Report. Changes in Australia's Mental Health Services under the
     First National Mental Health Plan of the National Mental Health Strategy 1993-98.
     Canberra, 2000.
     http://www7.health.gov.au/hsdd/mentalhe/resources/reports/pdf/nmhr2000.pdf
15   Commonwealth Department of Health and Aged Care. Promotion, Prevention and Early
     Intervention for Mental Health - A Monograph. Canberra: Mental Health and Special
     Programs Branch, Commonwealth Department of Health and Aged Care, 2000.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-mhinfo-
     ppei-monograph.htm
16   Commonwealth Department of Health and Aged Care. National Action Plan for
     Depression. Canberra: Mental Health and Special Programs Branch, 2000.
     http://www.mentalhealth.gov.au/resources/pdf/depression.pdf
17   Commonwealth Department of Health and Aged Care. National Action Plan for
     Promotion, Prevention and Early Intervention for Mental Health. Canberra:
     Commonwealth of Australia, 2000.
     http://www.health.gov.au/hsdd/mentalhe/mhinfo/ppei/pdf/actionplan.pdf
18   Commonwealth Department of Health and Aged Care. National Youth Suicide
     Prevention Strategy. Canberra: Australian Government, 2000.
     http://www.health.gov.au/hsdd/mentalhe/sp/nysps/about.htm
19   Elliot & Shanahan Research. Developmental research for a National Alcohol
     Campaign. Summary Report. Canberra: Commonwealth Department of Health and
     Aged Care, 1999. http://www.health.gov.au/pubhlth/publicat/document/alcocamp.pdf
20   Commonwealth Department of Health and Aged Care. National Health Priority Areas
     Report 1998. Mental health (a report focusing on depression). Summary. Canberra:
     Commonwealth of Australia, 1999.
     http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pq-mental-pubs-
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Canada
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6    Canadian Mental Health Association. Early Psychosis Intervention: Population Health
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Denmark
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                                            126
England
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15   National Institute for Mental Health in England. Mental Health Policy Implementation
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16   National Institute for Mental Health in England. Scoping review on Mental Health Anti
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18   Mentality. Literature & Policy Review for the Joint Inquiry into Mental Health and
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19   Mental Health Care Group Workforce Team. Mental Health Workforce Strategy.
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20   King's Fund. Mental health in prisons. London, 2004.
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24   Department of Health. The Mental Health and Psychological Well-being of Children
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25   Department of Health. Choosing Health? Choosing Activity: a consultation on how to
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26   Crowley P, Kilroe J, Burke S. Youth suicide prevention. Evidence briefing: Health
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27   Shaw J, Appleby L, Baker D. Safer Prisons. Manchester: Department of Health, 2003.
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28   NIMHE. Post-qualifying mental health training: Department of Health, 2003.
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29   NIMHE. Women-only and women-sensitive mental health services: Department of
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30   NIMHE. Employment for people with mental health problems: Department of Health,
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31   NIMHE. Self-help interventions for mental health problems: Department of Health,
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32   NIMHE. Early intervention for people with psychosis: Department of Health, 2003.
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33   NIMHE. Preventing Suicide - a toolkit for Mental Health Services: NHS, 2003.
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34   NIMHE, (National Institute for Mental Health in England). Contact a directory for
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35   National Statistics. Attitudes to Mental Illness 2003. London: Department of Health,
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37   Prison Health Policy Unit and Task Force. Health Promoting Prisons: a shared
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38   Department of Health. Women's Mental Health: Into the Mainstream. Strategic
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39   Department of Health. National Suicide Prevention Strategy for England. London: UK
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40   Department of Health. National Suicide Prevention Strategy for England. Consultation
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41   Prison Health Policy Unit and Task Force. Changing the Outlook. A strategy for
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42   Mentality. Making It Happen. A guide to delivering mental health promotion. London:
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43   Department of Health. National Service Framework for Older People. London: UK
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44   Department of Health. Reforming the Mental Health Act. London: UK Parliament,
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45   Home Office. Caring about Carers: National Strategy for Carers. London: UK
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46   Department of Health. National Service Framework for Mental Health. London: UK
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47   Department of Health. Modernising Mental Health Services. Safe, sound and
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Finland
1    The Mental Health Preparation and Monitoring Group. Quality Recommendation for
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6    Liimatainen M. Mental Health in the workplace: situation analysis, Finland. Geneva:
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9    Topo P. Mental health of the elderly in Finland: STAKES, 1999.
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10   Aromaa A, Koskinen S, Huttunen J. Health in Finland. Helsinki: National Public Health
     Institute (KTL) Ministry of Social Affairs, 1999.




Ireland
1    Crowley P, Kilroe J, Burke S. Youth suicide prevention. Evidence briefing: Health
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2    Barry M, Friel S, Dempsey C, Avalos G, Clarke P. Promoting Mental Health and Social
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5    Department of Health and Children. Quality and Fairness. A Health System for You.
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6    Department of Health and Children. The National Health Promotion Strategy 2000-
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8    The Irish Division of the Royal College of Psychiatrists. The Changing Minds
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10   Department of Health and Children. Report of the National Task Force on Suicide.
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Japan
1    WASP et al. Kobe Declaration: World Congress of Social Psychiatry, 2004.
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2    Ministry of Health and Welfare. National Health Promotion in the 21st Century (Health
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New Zealand
1    Platform, Support Services and Community Development in Mental Health. Advocacy
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6    Ministry of Social Development. Children and Young People: Indicators of Wellbeing
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19   Ministry of Health. Building on Strengths: A Guide for Action. A new approach to
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20   Ministry of Health. DHB Toolkit. Suicide Prevention. Wellington: New Zealand
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26   Ministry of Health. Suicide and the media. Wellington: New Zealand Government,
     1999.
     http://www.moh.govt.nz/moh.nsf/0/A72DCD5037CFE4C3CC256BB5000341E9/$File/
     suicideandthemedia.pdf
27   Ministry of Health. Better Times. Contributing to the Mental Health of Children and
     Young People. Wellington: NZ Government, 1999.
     http://www.moh.govt.nz/moh.nsf/0/357db0e1610bcff5cc256b9c007faef8/$FILE/bettert
     imes.pdf
28   National Health Committee. How should we care for the carers? Wellington: National
     Advisory Committee on Health and Disability, 1998.
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29   Ministry of Youth Affairs. Strengthening Youth Wellbeing. Kia Piki Te Ora O Te
     Taitamariki. Wellington, 1998. http://www.myd.govt.nz/media/pdf/kia_piki.pdf
30   Ministry of Health & Ministry of Youth Affairs & Ministry of Maori Development. In
     Our Hands. New Zealand Youth Suicide Prevention Strategy. Wellington, 1998.
     http://www.moh.govt.nz/moh.nsf/238fd5fb4fd051844c256669006aed57/1fc9af534d662
     c7ecc256cb00071f509?OpenDocument#suicide
31   Ministry of Health. New Futures. A strategic framework for specialist mental health
     services for children and young people in New Zealand. Wellington: New Zealand
     Government, 1998. http://www.moh.govt.nz/moh.nsf/Files/newftres/$file/newftres.pdf
32   Mental Health Commission. A Travel Guide for people on the journeys towards
     equality respect and rights for people who experience mental illness. Wellington: New
     Zealand Government, 1998.
     http://www.mhc.govt.nz/publications/1998/Travel_Guide.htm#travel
33   Mental Health Commission. Blueprint for Mental Health Services in New Zealand.
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34   Beautrais A. A Review of Evidence: In Our Hands - The New Zealand Youth Suicide
     Prevention Strategy. Wellington: Ministry of Health, New Zealand Government, 1998.
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35   Ministry of Health. Moving Forward. The National Mental Health Plan for More and
     Better Services. Wellington: New Zealand Government, 1997.
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36   New Zealand Guidelines Group. A guide to effective consumer participation in mental
     health services. Wellington: Ministry of Health, 1995.
     http://www.nzgg.org.nz/guidelines/0071/Consumer_Participation.pdf
37   Ministry of Health. Looking Forward. Strategic Directions for the Mental Health
     Services. Wellington: New Zealand Government, 1994.
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     1ac98cc256c39000857fb/$FILE/looking-forward.pdf




Northern Ireland
1    Ministry for Health Social Services and Public Safety. Investing for Health Update
     2004. Belfast: Northern Ireland Assembly, 2004.
     http://www.investingforhealthni.gov.uk/documents/ifh-update-2004(2).pdf
2    Health Promotion Agency for Northern Ireland. Annual report and accounts 2003-2004:
     Northern Ireland Assembly, 2004.
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     al%20report%202003.pdf
3    Department of Health, Social Services and Public Safety. A Healthier Future. A twenty
     year vision for health and wellbeing in Northern Ireland 2005-2025. Belfast: Northern
     Ireland Assembly, 2004. http://www.dhsspsni.gov.uk/publications/2004/healthyfuture-
     main.pdf
4    Department of Health, Social Services and Public Safety. A Healthier Future. A twenty
     year vision for health and wellbeing in Northern Ireland 2005-2025. Executive
     Summary. Belfast: Northern Ireland Assembly, 2004.
     http://www.dhsspsni.gov.uk/publications/2004/healthyfuture-execsummary.pdf
5    Crowley P, Kilroe J, Burke S. Youth suicide prevention. Evidence briefing: Health
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6    Northern Ireland Association for Mental Health N. Time for Change. Belfast: DHSSPS
     Review of Mental Health and Learning Disability (NI), 2003.
     http://www.niamh.co.uk/info.php?content=infopublications&submenu=Publications
7    Northern Ireland Association for Mental Health N. Counting the Cost: The Sainsbury
     Centre for Mental Health, 2003.
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8    Department of Health, Social Services and Public Safety. Promoting Mental Health.
     Strategy and Action Plan 2003-2008. Belfast: Northern Ireland Assembly, 2003.
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9    Ministry for Health Social Services and Public Safety. Valuing Carers. Belfast:
     Northern Ireland Assembly, 2002.
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                                           134
10   Ministry for Health Social Services and Public Safety. Investing for Health. Belfast:
     Northern Ireland Assembly, 2002.
     http://www.dhsspsni.gov.uk/publications/2002/investforhealth.asp
11   Barry M, Friel S, Dempsey C, Avalos G, Clarke P. Promoting Mental Health and Social
     Well-being: Cross-Border Opportunities and Challenges. Armagh: The Centre for Cross
     Border Studies, 2002. http://www.crossborder.ie/pubs/mentalhealth.pdf
12   Department of Health Social Services and Public Safety. Informal Carers Report.
     Belfast: Northern Ireland Assembly, 2001.
     http://www.dhsspsni.gov.uk/publications/archived/2001/informal_carers_report.pdf
13   Department of Health Social Services and Public Safety. Safety First Report
     2001:Summary. Belfast: Northern Ireland Assembly, 2001.
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14   Task Force on Mental Health Promotion. Minding Our Health. Belfast: Northern
     Ireland Ministry of Health, 1999.
     http://www.dhsspsni.gov.uk/publications/archived/2000/mohstrategy.pdf
15   Department of Health Social Services and Public Safety. Children First - strategy
     document for childcare in Northern Ireland. Belfast: Northern Ireland Assembly, 1999.
     http://www.dhsspsni.gov.uk/publications/archived/childrenfirst.htm




Norway
1    Ministry of Social Affairs. Prescriptions for a Healthier Norway. A broad policy for
     public health. Oslo: Norwegian Government, 2003.
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2    Ministry of Children and Family Affairs. National Report on Youth Policy in Norway.
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3    Ministry of Children and Family Affairs. UN Special Session on Children Norway's
     National Plan of Action: Norwegian Government, 2002.
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4    Norwegian Ministry of Health and Social Affairs. Mental Health Services in Norway.
     Oslo: Norwegian Government, 2001.
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5    Soras I. The Norwegian Plan for Suicide Prevention 1994-1999: Evaluation Findings.
     The Suicide Research and Prevention Unit: University of Oslo, 2000.
     http://www.med.uio.no/ipsy/ssff/engelsk/Soeraas.htm




Scotland
1    Scottish Executive Health Department. National Programme For Improving The Mental
     Health And Well-Being Of The Scottish Population. 2005.
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2    Crawford F. Doing it differently. Edinburgh: NHS Health Scotland and Scottish
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                                            135
3    Women and Children's Unit, Health Department. Children and Young People's Mental
     Health: A Framework for Promotion, Prevention and Care. Edinburgh: Scottish
     Executive, 2004. http://www.scotland.gov.uk/consultations/health/cypmh.pdf
4    Scottish Health Promoting Schools Unit 2004. Being Well - Doing Well. a framework
     for health promoting schools in Scotland. Edinburgh: Scottish Executive, 2004.
     http://www.healthpromotingschools.co.uk/files/beingwelldoingwell.pdf
5    Scottish Executive. National Programme for Improving Mental Health and Well-Being.
     Annual Review 2003-2004. Edinburgh: Scottish Executive, 2004.
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6    Risbey D. Volunteering in Mental Health and Well-Being: Volunteer Development
     Scotland. National Centre of Excellence, 2004.
     http://www.vds.org.uk/information/docs/reports/pdf2rpt0204VolunteeringInMentalHeal
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7    Parkinson J. Indicators of Mental Health and Well-being - Background Paper.
     Edinburgh: NHS Health Scotland, 2004.
     http://www.phis.org.uk/doc.pl?file=pdf/Mental%20Health%20background%20paper%2
     0revised2.doc
8    Grant S. National Mental Health Services Assessment. Towards Implementation of the
     Mental Health (Care and Treatment) (Scotland) Act 2003: Scottish Executive, 2004.
     http://www.scotland.gov.uk/library5/health/mnhsaf.pdf
9    Friedli L. Mental health, mental well-being and mental health improvement: what do
     they mean? Edinburgh: Scottish Executive, 2004.
     http://www.wellontheweb.org/well/files/conceptsbriefing-final.doc
10   Braunholtz S, Davidson S, King S, Scotland M. Well? What do you think?. The
     Second National Scottish Survey of Public Attitudes to Mental Health, Mental Well-
     being and Mental Health Problems. Edinburgh: Scottish Executive Social Research,
     2004. http://www.scotland.gov.uk/library5/health/pamhs.pdf
11   Scottish Executive. Well? Mental health and well being in Scotland, 2003-2004.
     http://www.scotland.gov.uk/library5/health/well3.pdf
12   Scottish Executive. Well? Mental health and well-being in Scotland. Edinburgh, 2003.
     http://www.show.scot.nhs.uk/sehd/publications/well2/well2.pdf
13   Scottish Executive. National Programme for Improving Mental Health and Well-Being.
     Edinburgh, 2003. http://www.scotland.gov.uk/library5/health/npmh.pdf
14   Scottish Executive. Improving Health in Scotland: The Challenge. Edinburgh: Scottish
     Parliament, 2003. http://www.scotland.gov.uk/library5/health/ihis.pdf
15   Scottish Executive. Partnership for Care. Scotland's Health White Paper. Edinburgh:
     NHS Scotland, 2003. http://www.scotland.gov.uk/library5/health/pfcs.pdf
16   Scottish Development Centre for Mental Health in Association with the Scottish
     Council Foundation and OPM. Building Community Well-Being. An Exploration of
     Themes and Issues. Edinburgh: Scottish Executive, 2003.
     http://www.scotland.gov.uk/library5/society/bcwm.pdf
17   Scottish Advisory Committee on Drug Misuse (SACDM) and Scottish Advisory
     Committee on Alcohol Misuse (SACAM). Mind the Gaps. Meeting the needs of people
     with co-occurring substance misuse and mental health problems. Edinburgh: Scottish
     Executive, 2003. http://www.scotland.gov.uk/library5/health/mtgd.pdf
18   Public Health Institute of Scotland. Needs Assessment Report on Child and Adolescent
     Mental Health. consulting children, young people and parents - May 2003. Edinburgh:
     Scottish Executive, 2003. http://www.phis.org.uk/pdf.pl?file=pdf/CAMH2.pdf




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19   Public Health Institute of Scotland. Needs Assessment Report on Child and Adolescent
     Mental Health. Final Report - May 2003. Edinburgh: Scottish Executive, 2003.
     http://www.phis.org.uk/pdf.pl?file=pdf/CAMH1.pdf
20   NHS Health Scotland. Dementia and Older People. Edinburgh: NHS Health Scotland,
     2003. http://www.phis.org.uk/pdf.pl?file=publications/dementia%20HNA.pdf
21   Gow J, Gilhooly M. Risk Factors for Dementia and Cognitive Decline. Edinburgh:
     NHS Health Scotland, 2003.
     http://www.phis.org.uk/pdf.pl?file=publications/dementia%20LR.pdf
22   Scottish Executive Health Department. National Anti-Stigma Campaign Update to
     members of the National Advisory Group. Edinburgh: Scottish Executive, 2002.
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23   Scottish Executive Health Department. Paper (02) 07 'Introduction to the National
     Programme Outline Plan'. Edinburgh: Scottish Executive, 2002.
     http://www.show.scot.nhs.uk/sehd/mentalwellbeing/Papers2.htm
24   Scottish Executive Health Department. Paper (02) 01 Background and Introduction to
     the National Programme. Edinburgh: Scottish Executive, 2002.
     http://www.show.scot.nhs.uk/sehd/mentalwellbeing/Papers1.htm
25   Scottish Executive. Well? Mental health and well being in Scotland, 2002.
     http://www.scotland.gov.uk/library5/health/mhm92.pdf
26   Scottish Development Centre for Mental Health. Preventing Suicide and Deliberate Self
     Harm. Laying the Foundations: Identifying Practice Examples. Summary of Project
     Report. Edinburgh: Scottish Executive, 2002.
     http://www.scotland.gov.uk/library5/health/sopr.pdf
27   Scottish Development Centre for Mental Health. National Framework for the
     Prevention of Suicide in Scotland. Exploring Experience: Summary. Edinburgh:
     Scottish Executive, 2002. http://www.scotland.gov.uk/library5/health/eesu.pdf
28   Mentality. Mental Health Improvement: What Works?: Scottish Executive, 2002.
     http://80.75.66.189/well/files/Evidence%20briefing%20Scotland%20(April%2003).doc
29   Expert Group on Healthcare of Older People. Adding Life to Years. Edinburgh:
     Scottish Executive, 2002. http://www.scotland.gov.uk/library3/health/alty.pdf
30   Department of Health and Community Care. Choose Life. A National Strategy and
     Action Plan to Prevent Suicide in Scotland. Edinburgh: Scottish Executive, 2002.
     http://www.scotland.gov.uk/library5/health/clss.pdf
31   Central Research Unit. National Framework for the Prevention of Suicide and
     Deliberate Self-harm in Scotland: Analysis of Written Submissions to Consultation.
     Edinburgh: Scottish Executive, 2002.
     http://www.scotland.gov.uk/cru/kd01/red/nfps.pdf
32   The Scottish Public Mental Health Alliance. With Health in Mind. Edinburgh: Scottish
     Executive Health Department, 2002.
     http://www.mentalhealth.org.uk/html/content/with_health_in_mind.pdf
33   Wood R, Bain M. The Health and Well-being of Older People in Scotland. Edinburgh:
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34   Scottish Executive. Renewing Mental Health Law. Policy Statement. Executive
     Summary. Edinburgh: Scottish Executive, 2001.
     http://www.scotland.gov.uk/library3/health/rhmls.pdf
35   Ministry for Health and Community Care. National Framework for the Prevention of
     Suicide and Deliberate Self-harm in Scotland. Edinburgh: Scottish Executive, 2001.
     http://www.show.scot.nhs.uk/sehd/publications/suicide/suicide%20consultation.PDF



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36   Millan B. New Directions. Report on the Review of the Mental Health (Scotland) Act
     1984. Executive Summary: Scottish Executive, 2001.
     http://www.scotland.gov.uk/health/mentalhealthlaw/Millan/Executive%20Summary/es
     mr.pdf
37   The Scottish Office Department of Health. Towards a Healthier Scotland. A White
     Paper on Health. Edinburgh: Secretary of State for Scotland, 1999.
     http://www.scotland.gov.uk/library/documents-w7/tahs-00.htm
38   The Scottish Office. A Framework for Mental Health Services in Scotland. Edinburgh,
     1997. http://www.show.scot.nhs.uk/publications/mental_health_services/mhs/index.htm




Sweden
1    Hogstedt C, Lundgren B, Moberg H, Pettersson B, Agren G. Swedish Public Health
     Policy and the National Institute of Public Health. Scand J Public Health 2004;32(Suppl
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2    Agren G. The Swedish Public Health Policy. Stockholm: National Institute of Public
     Health, 2001. http://www.fhi.se/pdf/policy.pdf
3    Agren G, Hedin A. The new Swedish public health policy. Stockholm: National
     Institute of Public Health, Sweden, 2000.
     http://www.fhi.se/shop/material_pdf/newswedish.prn.pdf




USA
1    The Carter Center Mental Health Program. The Rosalynn Carter Fellowships for
     Mental Health Journalism. Atlanta, 2004.
     http://www.cartercenter.org/documents/nondatabase/0506FellowsBrochure.pdf
2    New Freedom Commission on Mental Health. Achieving the Promise: Transforming
     Mental Health Care in America. Executive Summary. Rockville, MD: DHHS Pub No
     SMA-03-3831, 2003.
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3    US Department of Health and Human Services. National Strategy for Suicide
     Prevention: Goals and Objectives for Action. Rockville, MD: US Government, 2001.
     http://media.shs.net/ken/pdf/SMA01-3517/SMA01-3517.pdf
4    US Department of Health and Human Services. National Strategy for Suicide
     Prevention Goals and Objectives for Action: Summary. Washington DC: Surgeon
     General, 2001. http://www.mentalhealth.samhsa.gov/publications/allpubs/SMA01-
     3518/default.asp
5    US Department of Health and Human Services. Healthy People 2000 Final Review.
     Hyattsville, Maryland: Public Health Service, 2001.
     http://www.cdc.gov/nchs/data/hp2000/hp2k01.pdf
6    National Institute of Mental Health. The Numbers Count: Mental Disorder In America.
     A summary of statistics describing the prevalance. web site, 2001.
     http://www.nimh.nih.gov/publicat/numbers.cfm
7    US Department of Health and Human Services. Healthy People 2010. Washington DC:
     US Government Printing Office, 2000. http://www.healthypeople.gov/Publications/


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8    Department of Health and Human Services. Report of the Surgeon General's
     Conference on Children's Mental Health: A National Action Agenda. Washington, DC:
     US Government, 2000. http://www.hhs.gov/surgeongeneral/topics/cmh/cmhreport.pdf
9    US Public Health Service. The Surgeon General's Call to Action to Prevent Suicide.
     Washington DC: Department of Health and Human Services, 1999.
     http://media.shs.net/ken/pdf/suicideprevention/calltoaction.pdf
10   US Department of Health and Human Services. Mental Health: A Report of the
     Surgeon General - Executive Summary. Rockville, MD: US Department of Health and
     Human Services, Substance Abuse and Mental Health Services Administration, Center
     for Mental Health Services, National Institutes of Health, National Institute of Mental
     Health, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/ExSummary-
     Final.pdf




Wales
1    Chief Medical Officer. Health Status Wales 2004-2005. Cardiff: Welsh Assembly,
     2005. http://www.cmo.wales.gov.uk/content/publications/reports/health-status-wales-
     e.pdf
2    Welsh Assembly Government. Stronger in Partnership. Cardiff, 2004.
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3    Welsh Assembly Government. Mental Health Policy Guidance. Cardiff, 2003.
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4    Shaw J, Appleby L, Baker D. Safer Prisons. Manchester: Department of Health, 2003.
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5    Welsh Assembly Government. Adult Mental Health Services. A National Framework
     for Wales. Cardiff, 2002.
     http://www.wales.nhs.uk/sites/documents/438/adult%2Dmental%2Dnsf%2De%2Epdf
6    Prison Health Policy Unit and Task Force. Health Promoting Prisons: a shared
     approach. London: Department of Health and HM Prison Service, 2002.
     http://www.dh.gov.uk/assetRoot/04/03/42/65/04034265.pdf
7    Prison Health Policy Unit and Task Force. Changing the Outlook. A strategy for
     developing and modernising mental health services in prisons. London: Department of
     Health and HM Prison Service, 2001.
     http://www.dh.gov.uk/assetRoot/04/03/42/28/04034228.pdf
8    Ministry of Health and Social Services. Adult Mental Health Services for Wales.
     Equity, Empowerment, Effectiveness, Efficiency. Cardiff: The National Assembly for
     Wales, 2001. http://www.wales.gov.uk/subihealth/content/pdf/adult-health-e.pdf
9    Ministry for Health and Social Services. Child and Adolescent Mental Health Services.
     Everybody's Business. Cardiff: The National Assembly for Wales, 2001.
     http://www.wales.gov.uk/subihealth/content/pdf/men-health-e.pdf
10   Secretary of State for Wales. Better Health Better Wales: Strategic Framework. Cardiff:
     The National Assembly for Wales, 1998.
     http://www.wales.gov.uk/subihealth/content/keypubs/strategicframework/stratframewor
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11   Secretary of State for Wales. Better Health Better Wales: Green Paper. Cardiff: Welsh
     Parliament, 1998.
     http://www.wales.gov.uk/subihealth/content/keypubs/green/content_e.htm


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European Region
1    WHO European Ministerial Conference on Mental Health. Mental Health in Europe:
     Facing the Challenges, Building Solutions: Briefing Papers. Helsinki: WHO, 2005.
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2    WHO European Ministerial Conference on Mental Health. Mental Health Action Plan
     for Europe. Facing the Challenges, Building Solutions. Helsinki: WHO, 2005.
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3    WHO European Ministerial Conference on Mental Health. Mental Health Declaration
     for Europe. Facing the Challenges, Building Solutions. Helsinki: WHO, 2005.
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4    McDaid D, Knapp M, Curran C. Policy brief: Mental health III. Funding mental health
     in Europe. Copenhagen: European Observatory on Health Systems and Policies, 2005.
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5    McDaid D. Policy brief: Mental health I. Key issues in the development of policy and
     practice across Europe. Copenhagen: European Observatory on Health Systems and
     Policies, 2005. http://www.euro.who.int/Document/E85485.pdf
6    McDaid D, Thornicroft G. Policy brief: Mental health II. Balancing institutional and
     community-based care. Copenhagen: European Observatory on Health Systems and
     Policies, WHO, 2005. http://www.euro.who.int/Document/E85488.pdf
7    Jane-Llopis E, Anderson P. Mental Health Promotion and Mental Disorder Prevention.
     A Policy for Europe. Nijmegen: Radboud University Nijmegen, 2005.
     http://www.imhpa.net/fileadmin/imhpa/A_Policy_for_Europe.pdf
8    Wasserman D, Rutz E, Rutz W, Schmidtke A. Suicide Prevention in Europe.
     Stockholm: National and Stockholm County Council's Centre for Suicide Research and
     Prevention of Mental Ill-Health, 2004.
     http://www.ki.se/suicide/rapporter/Suicide_Prevention_in_Europe.pdf
9    Mental Health Europe. Guidelines for Country-based Programmes of Suicide
     Prevention. Brussels, 2004.
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10   Lehtinen V. Action for Mental Health. Activities co-funded from European
     Community Public Health Programmes 1997-2004. STAKES: European Commission,
     Health and Consumer Protection Directorate-General, 2004.
     http://europa.eu.int/comm/health/ph_determinants/life_style/mental/docs/action_1997_
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11   Health and Consumer Protection Directorate-General. Actions against depression:
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12   Health and Consumer Protection Directorate-General. The State of Mental Health in the
     European Union: Eruopean Commission, 2004.
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13   Mental Health in Europe New Challenges, New Opportunities. Report from a
     European Conference 9-11 October 2003, Bilbao, Spain; 2003.
     http://www.stakes.fi/verkkojulk/pdf/Themes3-2004.pdf




                                           140
14   WHO. Suicide Prevention in Europe. The WHO European monitoring survey on
     national suicide prevention programmes and strategies. Copenhagen: WHO, 2002.
     http://www.euro.who.int/document/E77922.pdf
15   European Commission. Guidance on work-related stress. Spice of life or kiss of death?
     Executive summary. Luxembourg: EU, 2002.
     http://europa.eu.int/comm/employment_social/publications/2002/ke4502361_en.pdf
16   WHO. Mental Health in Europe. Country reports from the WHO European Network on
     Mental Health. Copenhagen: WHO, 2001.
     http://www.euro.who.int/document/E76230.pdf
17   STAKES. Minimum data set of European mental health indicators: European
     Commission, 2001. http://www.stakes.fi/mentalhealth/seminar/pdf/indicators.pdf
18   Lavikainen J. Future Mental Health Challenges in Europe. The Impact of Other
     Policies on Mental Health. Brussels: STAKES, 2001.
     http://europa.eu.int/comm/health/ph/programmes/health/meeting_0512011_en.pdf
19   Lavikainen J. Future Mental Health Challenges in Europe: The Impact of Other Policies
     on Mental Health. Report of the consultative meeting, Brussels, 3-4 September 2001.
     Helsinki: STAKES, 2001. http://www.stakes.fi/mentalhealth/pdf/report_0512011.pdf
20   Lavikainen J, Lahtinen E, Lehtinen VE. Proceedings of the European Conference on
     Promotion of Mental Health and Social Inclusion, 10-13 October 1999, Tampere,
     Finland. Helsinki: Reports of the Ministry of Social Affairs and Health, 2001.
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21   Lavikainen J, Lahtinen E, Lehtinen V. Public Health Approach on Mental Health in
     Europe. STAKES: Ministry of Social Affairs and Health, 2000.
22   Bille-Brahe U. Suicidal Behaviour in Europe. The situation in the 1990s. Copenhagen:
     WHO Europe, 1998. http://www.euro.who.int/document/E60709.pdf




World Health Organisation
1    WHO. WHO Resource Book on Mental Health, Human Rights and Legislation. Stop
     exclusion, dare to care. Geneva: WHO, 2005. http://www.ruig-
     gian.org/proj/WHOResourceBook050210.pdf
2    WHO European Ministerial Conference on Mental Health. Mental Health in Europe:
     Facing the Challenges, Building Solutions: Briefing Papers. Helsinki: WHO, 2005.
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3    WHO European Ministerial Conference on Mental Health. Mental Health Action Plan
     for Europe. Facing the Challenges, Building Solutions. Helsinki: WHO, 2005.
     http://www.euro.who.int/document/mnh/edoc07.pdf
4    WHO European Ministerial Conference on Mental Health. Mental Health Declaration
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                                          143
Appendix 2
Examples of non-government mental health organisations

National

Body                                             Website address
Carers Australia                                 http://www.carersaustralia.com.au/

Multicultural Mental Health Australia            http://www.mmha.org.au/

SPA (Suicide Prevention Australia)               http://www.suicidepreventionaust.org/

Sane                                             http://www.sane.org/

Canadian Mental Health Association               http://www.cmha.ca/english/

Schizophrenia Society of Canada                  http://www.schizophrenia.ca/

SIND (Danish Association for Mental Health)      http://www.sind.dk/ (Danish)
                                                 http://www.hkhkronprinsen.dk/29e0029

Mind                                             http://www.mind.org.uk/

MindOUT                                          http://mindout.clarity.uk.net/

The Finnish Association for Mental Health        http://www.mielenterveysseura.fi/english.asp?m
                                                 ain=English

Finnish Association on Mental Retardation        http://www.kehitysvammaliitto.fi/frontpage
                                                 (Finnish)

Mental Health Ireland                            http://www.mentalhealthireland.ie/default.asp

Japanese Association for Mental Health           http://read.jst.go.jp/ddbs/plsql/KKN_EG_14?co
                                                 de=J235000000

Caring for Carers                                http://www.caringforcarers.org.nz/

Pathways Trust                                   http://www.pathways.co.nz/

Youth Horizons                                   http://www.youthorizons.org.nz/default.asp?sect
                                                 ionID=1

Alzheimers Society Northern Ireland              http://www.alzheimers.org.uk/Your_local_bran
                                                 ch/Regions_and_Branches/region_ni.htm

Northern Ireland Association for Mental Health   http://www.niamh.co.uk/index.php?content=&s
                                                 ubmenu=Home



                                         144
Mental Helse Norway                               http://www.mentalhelse.no/    (Norwegian)

Scottish Association for Mental Health (SAMH)     http://www.samh.org.uk/

The Swedish National Association for              http://www.sfph.se/liston/1171_1.lxml
Mental Health

Swedish National Association for Social           http://www.rsmh.se/english.htm
and Mental Health

Anxiety Disorder Association of America           http://www.adaa.org/

National Association for Self-Esteem              http://www.self-esteem-nase.org/

Depression and Related Affective Disorder         http://www.drada.org/
Association

Mind                                              http://www.mind.org.uk/
Samaritans                                        http://www.samaritans.org.uk/
Depression Alliance                               http://www.depressionalliance.org/
SANE                                              http://www.sane.org.uk/
The Mental Health Foundation                      http://www.mentalhealth.org.uk/
PAPYRUS (Prevention of Suicides)                  http://www.papyrus-uk.org/
Defeat Depression                                 http://www.depression.org.uk/


National Umbrella Mental Health Organisations

Lifeline                                          http://www.lifeline.org.au/

Mental Health Council of Australia                http://www.mhca.com.au/default.html

National Institute for Mental Health in England   http://www.nimhe.org.uk/

International Mental Health Professionals         http://www.imhpj.org/about_IMHPJ/constit
Japan                                             ution.shtml

Mental Health Foundation of New Zealand           http://www.mentalhealth.org.nz/page.php?2

Platform                                          http://www.platform.org.nz/links/platform_1
                                                  _1.php

See Me Scotland                                   www.seemescotland.org

National Alliance for the Mentally Ill            http://www.nami.org/

National Mental Health Association                http://www.nmha.org/

MACA (Mental After Care Association)              http://www.maca.org.uk/index.asp?i
                                                  d=1


                                          145
Mentality                                          http://www.mentality.org.uk/index.h
                                                   tm
UKAN (United Kingdom Advocacy Network)
                                                   http://www.u-kan.co.uk/
NIMHE (National Institute for Mental Health
in England)                                        www.nimhe.org.uk




International Mental Health Organisations

Alcoholics Anonymous                               www.alcoholics-anonymous.org

Interminds                                         www.interminds.org/htm

Gamblers Anonymous                                 http://www.gamblersanonymous.org/

MHCA (Mental Health Corporation of                 http://www.mhca.com/
America Inc)

International Stress Management Association        http://www.isma.org.uk/




International Umbrella Mental Health Organisations

World Federation for Mental Health                 http://www.wfmh.org/

Mental Health Europe                               http://www.mhe-sme.org/en/about.htm

EUFAMI (European Federation of Associations        http://www.eufami.org/index.pl
of Families of People with Mental Illness)

International Initiative for Mental Health         http://www.iimhl.com/default.asp
Leadership (IIMHL )

SPRC Suicide Prevention Resource Centre            www.sprc.org




                                             146

				
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