The number one obstacle to better mental health care is the stigmatization of people with mental illness. And stigmatization occurs on every level of society, according to psychiatrist Norman Sartorius, who has been a leading figure in the international promotion of mental health for half a century.
One hundred and seventy-five million years. That’s how many years of human life were affected by mental illness in 2010, representing a vast blighting and blunting of individual experience.
That makes mental and substance-use disorders the world’s leading contributors to years lived with disability.1 But the principle of “global solutions for global problems” hasn’t applied to mental illness in the same way it has to other widespread illnesses – as psychiatrist Norman Sartorius can attest to with numerous examples.
After a long international career fighting for better prevention and treatment of mental and neurological disorders – most notably as the first director of WHO’s Division of Mental Health – Dr. Sartorius is now active in NGOs and as a consultant and lecturer.
He recounts the story of a UN summit that recently convened to put global action on non-communicable diseases on the international agenda.2 Cancer, heart disease, COPD and diabetes were all included as matters of “profound concern” to the General Assembly. But mental illness didn’t appear on the list. He says it wasn’t until later, in response to pressure by several national delegations, that the summit inserted a sentence in its declaration acknowledging that mental and neurological disorders also contribute to the global burden of disease. “It was really shameful that mental illness hadn’t been included,” he says. “And this happened in 2011.”
Even one penny is too much
It’s a paradox. Mental illness constitutes a staggering burden of disease, yet it isn’t a priority. The reasons are many. Dr. Sartorius points to the entrenched distance between psychiatry and other medical disciplines.
He underscores the fact that for a long time, there weren’t any effective treatment options. But he identifies the chief cause not in any lack of knowledge or treatments, but in the stigmatization of mental illness. The stigma of mental illness marks not only people who suffer from it, but also their families and the people who provide them with care and mental health services. And it leads to discrimination that affects people in all walks of life.
WHO recently characterized the stigmatization of the mentally ill as “a hidden human rights emergency.”3 To illustrate the problem, Dr. Sartorius says that even when inexpensive medicines are available, it doesn’t guarantee that governments and health care providers will supply them. Why? “Because the mentally ill patient is considered by them as having no value,” he explains. “And if he is of no value, then any treatment is too expensive. Even one penny is too much.”
Dr. Sartorius maintains that the number one obstacle to effective treatment, buried deep within governments, public health agencies, health services and the general public, is stigmatization. He asks rhetorically, “Who wants to help a person with schizophrenia? If he dies sooner, that’s a decrease in cost.”
Among health care providers, stigmatization leads to discrimination in treating the physical illnesses that commonly affect those suffering from mental illness. For instance, mentally ill heart patients are offered coronary bypasses and angioplasties only half as often as ordinary heart patients. Dr. Sartorius says that generally speaking, people with mental disorders who come seeking help for a physical illness may find that non-psychiatric health care personnel don’t believe them, give them substandard care, use insulting language and treat them without empathy. “You would never say about somebody that he is a pneumonic. But the mentally ill patient – he is no longer Mr Smith. He is a schizophrenic.”
I would select depression
What can be done to help? Dr. Sartorius doesn’t put much stock in short-term anti-stigma campaigns that target the general public. Efforts to combat stigma must be a routine part of mental health services. In addition, he says, roundabout ways can sometimes be used to obtain better care for mental illnesses. People who are mentally ill are often subject to a range of other conditions such as heart disease and diabetes. Health decision makers across the world are becoming increasingly aware of the need to address these conditions because of their epidemic growth. This situation can be turned to good account, says Dr. Sartorius. One can lobby decision makers to do something about mental illness – because treating them will reduce the costs and complications of chronic physical illnesses.
These days, Dr. Sartorius is involved in a multi-country project that uses this very approach. It works like this: diabetes has been exploding in most parts of the world, consuming large portions of national health budgets. The long-term complications of diabetes, such as eye and nerve damage, are particularly costly. At the same time, there is evidence that patients with diabetes who also suffer from depression develop long-term complications twice as often as other diabetic patients. The project’s strategy is quite simple, Dr. Sartorius explains: “We said, ‘Let’s deal with depression so as to reduce the complications of diabetes.’ They answered, ‘Oh! Treating depression will reduce complications of diabetes? We should certainly do that.’”4
If Dr. Sartorius were permitted to choose one – and only one – thing to lobby for in order to improve global mental health, he knows what it would be. “I would select depression. Because of its eminent treatability, because it is often co-morbid with other illnesses, and because of the large number of people it affects.”
He pauses briefly. “And then I would insist that we start taking measures to prevent mental illness.”
The friend of the elderly
Dr. Sartorius’ calendar is booked solid with work-related activities around the world. Half a century of effort, in a field that offers many frustrations, has made him an optimist about the long term. Time is on the side of everyone who works to improve the state of mental health, he believes. And if you question his faith in progress, he’ll remind you of where things stood in the old days. The mentally ill had few legal protections, and there was little sense of moral obligation to look after people with mental illness, especially since there were no effective treatments for it at that time.
Take senile dementia, for instance. In the not-so-distant past, there were institutions that left their windows open in winter so that those with dementia would contract pneumonia. “This happened in Europe, and it happened in my time. They used to call pneumonia ‘the friend of the elderly.’ ”
Such behaviour is no longer acceptable. Humanity is evolving, insists Dr. Sartorius, and people are improving as moral beings all the time. “Today, we offer these patients food, shelter, warmth. The money for that is spent out of moral obligation.”
People who work in mental health promotion have to be indefatigable; achieving goals in this field sometimes takes decades. When Dr. Sartorius first assumed responsibility for mental health at WHO in the 1970s, few countries had a national mental health policy.
In time, such policies became common, even if the process was often drawn out for decades. For instance, China took the first steps towards formulating a mental health law in the early 1980s, yet the law still wasn’t in place when Dr. Sartorius left WHO in 1993.
It wasn’t until 2013, after some thirty years of effort, that the law was finally adopted. Of course, adoption does not always guarantee implementation, but Dr. Sartorius predicts that the law will succeed in China, thanks to one key circumstance.
“This law has been passed with substantial budgetary support, which shows us that the Chinese government really means it,” he notes. Time and again, he has heard decision makers assure him that they recognize the importance of mental health. “But that is not enough,” Dr. Sartorius smiles. “Their statements have to be supported financially.”
On a more personal note, Dr. Sartorius thinks that people who are working for better mental health should not rely too much on long-range programmes in which everything is planned from A to Z. A long working life has taught him another rule to live by: sometimes, in addition to good planning, you have to rely on luck and adopt a strategy of what he calls “enlightened opportunism.”
But how? Dr. Sartorius explains that you must keep yourself in a state of watchful preparation and look for opportunities. Understand your local surroundings and their needs, and stand ready with the best tools. Opportunities will arise; luck will come. “And then…,” he says, and makes a sudden gesture, “you pounce!”
- Whiteford H et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010, The Lancet Epub, 2013.
- NCD Alliance. Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, 2011.
- WHO Quality Rights Project – addressing a hidden emergency, 2011.
- Sartorius N, Cimino L. The Dialogue on Diabetes and Depression Initiative: Origins and achievements. Journal of Affective Disorders, 2012, 142S1: 4-7.
Norman Sartorius M.D., Ph.D.
Previous positions (selected)
• Director, Division of Mental Health, WHO
• President, World Psychiatric Association
• President, Association of European Psychiatrists
Current positions (selected)
• Professorial appointments at universities in several countries, including the UK, the US and China
• President, International Association for the Promotion of Mental Health Programmes
• Co-editor and advisory board member, various scientific journals
• Public health
• Stigmatization and its consequences
• Co-morbidity of mental and physical illness
• Cross-cultural and epidemiological psychiatry