HEALTH TOPICS A TO Z

The undefined burden of mental problems refers to the economic and social burden for families, communities and countries. Although obviously substantial, this burden has not been efficiently measured. This is because of the lack of quantitative data and difficulties in measuring and evaluating.

The hidden burden refers to the burden associated with stigma and violations of human rights and freedoms. Again, this burden is difficult to quantify. This is a major problem throughout the world, as many cases remain concealed and unreported.

Undefined burden

Mental illnesses affect the functioning and thinking processes of the individual, greatly diminishing his or her social role and productivity in the community. In addition, because mental illnesses are disabling and last for many years, they take a tremendous toll on the emotional and socio-economic capabilities of relatives who care for the patient, especially when the health system is unable to offer treatment and support at an early stage. Some of the specific economic and social costs include:

• lost production from premature deaths caused by suicide (generally equivalent to, and in some countries greater, than deaths from road traffic accidents);
• lost production from people with mental illness who are unable to work, in the short, medium or long term;
• lost productivity from family members caring for the mentally-ill person;
• reduced productivity from people being ill while at work;
• cost of accidents by people who are psychologically disturbed, especially dangerous in people like train drivers, airline pilots, factory workers;
• supporting dependents of the mentally ill person;
• direct and indirect financial costs for families caring for the mentally-ill person;
• unemployment, alienation, and crime in young people whose childhood problems, e.g., depression, behaviour disorder, were not sufficiently well addressed for them to benefit fully from the education available;
• poor cognitive development in the children of mentally ill parents, and the
• emotional burden and diminished quality of life for family members.

The hidden burden

Stigma can be defined as a mark of shame, disgrace or disapproval which results in an individual being shunned or rejected by others. The stigma associated with all forms of mental illness is strong but generally increases the more an individual's behaviour differs from that of the 'norm'.

Because of stigma, persons suffering from a mental illness are:

• often rejected by friends, relatives, neighbours and employers leading to aggravated feelings of rejection, loneliness and depression;
• often denied equal participation in family life, normal social networks, and productive employment;
• Stigma has a detrimental effect on a mentally ill person's recovery, ability to find access to services, the type of treatment and level of support received and acceptance in the community;
• Rejection of people with mental illness also affects the family and caretakers of the mentally ill person and leads to isolation and humiliation; and
• A major cause of stigma associated with mental illness are the myths, misconceptions and negative stereotypes about mental illness held by many people in the community.

The stigma can be reduced by:

• openly talking about mental illness in the community;
• providing accurate information on the causes, prevalence, course and effects of mental illness;
• countering the negative stereotypes and misconceptions surrounding mental illness;
• providing support and treatment services that enable persons suffering from a mental illness to participate fully in all aspects of community life;
• ensuring the existence of legislation to reduce discrimination in the workplace, in access to health and social community services.

Human rights violations

Persons experiencing mental problems are more vulnerable than others in their social dealings and, as a result, are at a relatively higher risk to have their human rights and freedoms violated. These include:

• the right not to be discriminated against (e.g., in access to health care, social services or employment);
• the right to liberty (e.g., not to have restrictions automatically imposed on freedom of movement through measures such as detention);
• the right to integrity of the person (e.g., not to be unduly subjected to mental or physical harm. Typical violations include treatment that ignores the requirement to obtain either the patient's informed consent or a surrogate decision-maker's, and sexual abuse);
• The right to control one's own resources (e.g., one should not be automatically removed on the mere grounds of status as a mental patient, but should be judged on his or her actual ability to manage resources).

Mental health legislation - a necessary requirement

General principles for mental health legislation to protect the rights of the mentally ill include:

• Respect for individuals and their social, cultural, ethnic, religious and philosophical values.
• Individuals' needs taken fully into account. Individual's need for health and social care must be assessed thoroughly. In particular, it is important to ensure that the views of an individual (and his or her carers) are considered. For this to happen, there must be close liaison between health, housing and social care services.
• Care and treatment provided in the least restrictive environment. In order to uphold this principle, legislation should be framed so that involuntary (formal) hospital admission is a last resort. This can be achieved through: clearly defined grounds for detention; procedural safeguards when the power to detain is used; an obligation to discharge when grounds for detention are no longer met; an independent review of the decision to detain.

• Provision of care and treatment aimed at promoting each individual's self- determination and personal responsibility. It is vital that individuals are given the opportunity to exercise choice and make decisions about their own care and treatment. Legislation should aim to ensure that: treatment can be imposed only in strictly limited and clearly defined circumstances and must be the least restrictive alternative; where individuals are unable to make decisions for themselves, steps are taken to find out their wishes and feelings; clear information on treatment and detention is readily available; appropriate provisions for confidentiality are in force.
• Provision of care and treatment aimed at achieving the individual's own highest attainable level of health and well-being. In addition, to issues of quality and continuity of care, this principle addresses the question of a "right" to treatment. It can also cover more general issues such as the requirement that the individual should be cared for properly in a safe environment and subject only to restrictions for reasons of his or her health or safety, or the safety of others. In this regard: there should be no restrictions on an individual's contact with friends and family, except in rare and clearly defined circumstances; stringent safeguards from abuse, exploitation and neglect should be in place.