Combining health and social protection measures to reach the ultra ...

Access to health“Two months ago I went to my home village. I went for acoffee at a café. Most people there, of those who wereaware of my problem, call me ‘mad’. More specificallythey said ‘Here is the lunatic’. That incident made mevery sad, I quickly finished my coffee and I left”. Tom.encouragement to go for mental health assessment andtreatment does often work 52 .It is fair to include not only individual but also systemicfactors in trying to understand the puzzle of under-treatment.In the USA the National Depressive and Manic-DepressiveAssociation undertook an investigation to explore why “thereis overwhelming evidence that individuals with depressionare being seriously under-treated”. They concluded that the“reasons for the continuing gap include patient, provider andhealth care system factors. Patient-based reasons include:failure to recognize the symptoms, underestimating theseverity, limited access, reluctance to see a mental healthcare specialist due to stigma, noncompliance with treatmentand lack of health insurance. Provider factors include poorprofessional school education about depression, limitedtraining in interpersonal skills, stigma, inadequate time toevaluate and treat depression, failure to considerpsychotherapeutic approaches, and prescription ofinadequate doses of antidepressant medication forinadequate durations. Mental health care systems createbarriers to receiving optimal treatment” 53 .Are people in rural areas better or worse served than thosein towns and cities? The evidence here is patchy but a clearoutline does tend to emerge. If a person with a mental illnesswants to keep personal information confidential, this seemsto be more difficult in rural communities. A study in Arkansas,for example, compared over 200 urban and rural residents’views about depression and its treatment. The rural residentswith a history of depression labelled people who soughtprofessional help more negatively than their urbancounterparts. By the same token, those who labelleddepression more negatively were less likely to have soughtprofessional help 54 .Similar findings also emerged from a study in Iowa wherepeople living in the most rural environments were more likelyto hold stigmatizing attitudes towards mental health care thanpeople in towns, and such views strongly predicted willingnessto seek care 55 . Perhaps for these reasons, a survey of ruralresidents in Virginia found that over a third of the populationhad a diagnosed mental disorder, but only 6% subsequentlysought help, that those who did not go for treatment said thatthey “felt there was no need” 56 . Evidence from Tennessee alsoshowed that among people who were mentally unwell, thosemore likely to seek help were women, younger people andthose who had been treated for a mental illness previously 57 .There is some evidence that these factors also prevent ruralchildren with mental illness from having access to mentalhealth care. A study of parents in rural areas of North Carolinaconcluded that although as many as 20% of children hadsome type of treatable mental illness, only about one third ofthem received help from the mental health system 58,59 . Theresearchers found that one of the main barriers to care wasstigma towards the use of the mental health care.So it seems to be true that stigma about mental illness isno less in many rural areas, and may be even stronger thanin towns and cities. In part this may be based upon fears thata rural community will learn details about a period of mentalillness, while it is easier in cities to remain anonymous. Butrelatively little research has been done in rural areas tounderstand these processes in more detail. This is especiallyimportant because there are relatively high rates of suicideamong male farmers in many countries 60-67 .In summary, this paper shows that stigmatization againstpeople with mental illness is common wherever it has beenstudied, and that these processes present formidable barriersboth to social inclusion and to proper access to mental healthcare. As the disabilities associated with mental illness exceedthose of most other disorder groups 68,69 , now is the time to: (i)undertake evidence-based interventions to reduce stigma;(ii) increase access to mental health treatment and care; and(iii) to scale up the available services in proportion to themagnitude of the need 70 . ❏Acknowledgement: The quotations and some elements of thetext are adapted from: Thornicroft G. (2006) Shunned:discrimination against people with mental illness. OxfordUniversity Press, Oxford.Graham Thornicroft is Professor of Community Psychiatry, andHead of the Multi-disciplinary Health Service and PopulationResearch Department at the Institute of Psychiatry, King’s CollegeLondon. He is a consultant psychiatrist and is Director of Researchand Development at the South London and Maudsley NHS Trust.He chaired the External Reference Group for the National ServiceFramework for Mental Health in England. His areas of researchexpertise include: stigma and discrimination, mental health needsassessment, the development of outcome scales, costeffectivenessevaluation of mental health treatments, and mentalhealth services in less economically developed countries. He hasauthored and co-authored 20 books and over 180 papers in peerreviewedjournals.“In my village they don’t know that I am living at agroup home and that I am on medication. I have toldthem that I am working at a shop in Athens. My closerelatives know it and some of them were moresupportive after I got sick than before. In my village Idon’t want them to know about it because I don’t wantpeople to say things about me”. Diana.064 ✜ Global Forum Update on Research for Health Volume 4