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This paper summarizes the findings for the East and South East Asia Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Im-plementation of Community Mental Health Care. The paper presents a description of the region, an overview of mental health policies, a critical ap-praisal of community mental health services developed, and a discussion of the key obstacles and challenges. The main recommendations address the needs to campaign to reduce stigma, integrate care within the general health care system, prioritize target groups, strengthen leadership in policy mak-ing, and devise effective funding and economic incentives.

This paper summarizes the findings for the Latin American and Caribbean countries of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. It presents an overview of the provision of mental health services in the region; describes key experiences in Argentina, Belize, Brazil, Chile, Cuba, Jamaica and Mexico; and discusses the lessons learned in developing community mental health care.

Peer support is largely considered to represent a recent advance in community mental health, introduced in the 1990s as part of the mental health service user movement. Actually, peer support has its roots in the moral treatment era inaugurated by Pussin and Pinel in France at the end of the 18th century, and has re-emerged at different times throughout the history of psychiatry. In its more recent form, peer support is rapidly expanding in a number of countries and, as a result, has become the focus of considerable research. Thus far, there is evidence that peer staff providing conventional mental health services can be effective in engaging people into care, reducing the use of emergency rooms and hospitals, and reducing substance use among persons with co-occurring substance use disorders. When providing peer support that involves positive self-disclosure, role modeling, and conditional regard, peer staff have also been found to increase participants' sense of hope, control, and ability to effect changes in their lives; increase their self-care, sense of community belonging, and satisfaction with various life domains; and decrease participants' level of depression and psychosis.

This paper summarizes the findings for North America of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. Community mental health has evolved over five decades in the United States and Canada. The United States has led the world in innovation and spending, but provide variable quality of care; Canada has steadily developed a more uniform public health system for less cost. Lessons learned from North America include: team-based approaches and other evidence-based practices, when implemented with high fidelity, can improve outcomes in routine mental health care settings; recovery ideology and peer support enhance care, though they have not been studied rigorously; effective community-based care for people with serious mental disorders is expensive.

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies’ countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society’s policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society’s members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies’ countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.

Comprehensive clinical assessment and patient management plans have been enhanced by the development of multiaxial classificatory systems. Assessment of risk is an essential clinical task for which the conclusions are not currently reflected in the multiaxial diagnostic schemata. Developments in the understanding of risk and its management make possible consideration of its place in multiaxial systems. The structure and principles of a potentially workable axis, summarizing current knowledge of risk in the domains of suicide, self-neglect and violence to others, are described. Clinicians are more likely to use this axis than the multiple, emerging, risk assessment guidelines. Incorporating risk management would be a practical addition to presently available axes and be very widely clinically applicable.

This paper summarizes the current situation of mental health services in the Arab world. Out of 20 countries for which information is available, six do not have a mental health legislation and two do not have a mental health policy. Three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. The highest number of psychiatrists is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists for 100,000 population. The budget allowed for mental health as a percentage from the total health budget, in the few countries where information is available, is far below the range to promote mental health services. Some improvement has occurred in the last decade, but the mental health human resources and the attention devoted to mental health issues are still insufficient.

This paper summarizes the findings for the African Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. We present an overview of mental health policies, plans and programmes in the African region; a summary of relevant research and studies; a critical appraisal of community mental health service components; a discussion of the key challenges, obstacles and lessons learned, and some recommendations for the development of community mental health services in the African region.

Healthcare workers are unevenly distributed around the globe, with countries carrying the highest burden of diseases having the lowest numbers of health workers while those with relatively low need have the highest numbers. Africa, for example, carries 25% of the world’s disease burden, yet has only 3% of the world’s health workers and 1% of the world’s economic resources to meet the challenge. The World Health Organization (WHO) identified 57 countries with critical shortage of healthcare workers, and 36 of these countries are in Africa 1. Assessment of global shortfall for health workers using the Joint Learning Initiative 2 analysis revealed the greatest shortage in the health workforce to be in South-East Asia, and the largest relative need to be in Sub-Saharan Africa, where an increase of almost 140% is necessary to meet the threshold 1. Emigration of highly skilled health professionals from less developed to developed countries, a phenomenon popularly known as “brain drain”, has been recognised since the 1960s and has attracted frequent commentaries 3, 5. The brain drain of skilled healthcare personnel creates imbalances in global health workforce 6 and serious human resource problems to health ministries of the home countries 7. In sub-Saharan Africa, brain drain in the health field severely limits even basic health service infrastructure 8, 11. Highly qualified doctors and nurses who would have played important clinical and supervisory roles in their health system emigrate to industrialised countries, causing a weakening of the capacities of such system to provide essential services to those in need. The current situation in Africa is different from that of the 1980s, when skilled professionals emigrated to developed countries to acquire knowledge and skills but then returned home, better equipped to serve their countries 12.

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies' countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society's policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society's members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies' countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.

This paper reviews the origins of the current concept of mental health, starting from the mental hygiene movement, initiated in 1908 by consumers of psychiatric services and professionals interested in improving the conditions and the quality of treatment of people with mental disorders. The paper argues that, more than a scientific discipline, mental health is a political and ideological movement involving diverse segments of society, interested in the promotion of the human rights of people with mental disorders and the quality of their treatment.

The World Health Organization (WHO) has for long proposed the development of community-based mental health services worldwide. However, the progress toward community mental health care in most African countries is still hampered by a lack of resources, with specialist psychiatric care essentially based in large, centrally located mental hospitals. It is again time to reconsider the direction of mental health care in Africa. Based on a small inquiry to a number of experienced mental health professionals in sub-Saharan Africa, we discuss what a community concept of mental health care might mean in Africa. There is a general agreement that mental health services should be integrated in primary health care. A critical issue for success of this model is perceived to be provision of appropriate supervision and continuing education for primary care workers. The importance of collaboration between modern medicine and traditional healers is stressed and the paper ends in a plea for WHO to take the initiative and develop mental health services according to the special needs and the socio-cultural conditions prevailing in sub-Saharan Africa.

Psychiatrists as a group are vulnerable to experiencing burnout, more so than other physicians and surgeons. In this paper, various definitions of burnout are reviewed and the tools available for quantifying burnout are compared. The factors that make psychiatry a stressful profession are also examined. These include factors such as patient violence and suicide, limited resources, crowded inpatient wards, changing culture in mental health services, high work demands, poorly defined roles of consultants, responsibility without authority, inability to effect systemic change, conflict between responsibility toward employers vs. toward the patient, and isolation. In order to investigate how exposure to such stressors results in burnout, two theoretical models are examined. Recommendations are also made, on the basis of anecdotal reports, for addressing burnout in psychiatrists.

The role of psychiatrists into public mental health clinics has been hampered by a perceived restriction of the psychiatrist's role to prescribing and sign-ing forms, limiting opportunities to engage in the kind of integrated care that attracted many physicians to this specialty. We propose a revision of the current model in a direction that maximizes the expertise of this specialist as well as other clinicians in the health care team. The basic unit would consist of a psychiatrist (with adequate background both in psychopharmacology and psychotherapy), an internist and four clinical psychotherapists, who may provide evidence-based treatment after the initial evaluation of the psychiatrist. Its functioning would emphasize repeated assessments, sequential combi-nation of treatments, and close coordination of team members. Re-invigorating the role of the psychiatrist in the context of a team in which role assign-ments are clear could result in better outcomes and enhanced recruitment of psychiatrists into the public sector.

Disastrous events in the country and the region caused a 13.5% increase in the prevalence of mental and behavioral disorders in Serbia in the last few years, thus making them the second largest public health problem. Due to prolonged adversities, the health system has deteriorated and is facing specific challenges. However, the reform of mental health care has been initiated, with a lot of positive movements such as the preparation of a national policy for mental health care and a law for protection of mentally ill individuals. The transformation of mental health services has started, with an accent on community care, antistigma campaigns and continuing education. Based on an assessment carried out by the National Committee on Mental Health, service provision, number of professionals working in services, funding arrangements, pathways into care, user/carer involvement and other specific issues are reported.

This paper summarizes political and social changes in Europe that directly affect the training of psychiatrists and the provision of mental health services. In Western Europe the demands of service users have led to a closer integration of social and health services, and a closer working and training of health professionals. The European psychiatrist of the future will be an internationalist, familiar with the impact of culture on mental disorders and able to work in a multi-professional team.

Uganda has passed through political and bloody civil strife stretching over 40 years. Since 1987 the HIV/AIDS pandemic has compounded the problems of the country. The present paper describes some initiatives to develop mental health services in one district of the country. A bottom-up approach in the district resulted in the formation of a community-led mental health program with strong support from two self-help groups, district political leaders and district representatives in parliament. Primary health care providers at all levels of health care in the district were trained in order to make services accessible to the rural population. Further plans based on initial exploratory discussions aim to involve the education department, the welfare and probation office, prisons and police, the military, church and cultural leaders and traditional healers. These initiatives show that it is possible to empower communities to participate in the development of mental health programs in a low-income country.

The South Asian region accounts for around one fourth of the world population and one fifth of psychiatrically ill patients in the world. The region lacks mental health policies and infrastructure. Issues like community care, trained manpower, patient satisfaction and better legislation have been a focus of attention in recent years. As this region is fast developing, cooperation is needed in the field of mental health to keep pace with the other areas. Cooperation is needed to develop culturally acceptable forms of psychotherapy and new technologies for delivery of mental health services. Another area of potential cooperation is the development of a classification of mental disorders that is more informative in our setting. The development of a mental health programme and its inclusion at various levels of health care delivery has also gained precedence. As most of countries in the area have limited financial resources, the funds are to be used in the most cost-effective manner, and for this a greater collaboration amongst the countries is needed. New research needs to be undertaken in the area especially to meet the local requirements and to understand diseases in a regional perspective, but research cannot be fruitful if regional cooperation is lacking. To enhance the cooperation in mental health, world bodies like the WPA will need to come forward and bring all the countries at a common platform. The WPA has done commendable work in this regard and has always extended support to the regional bodies to uplift the mental health in this region.

In 2005, the World Health Organization (WHO) launched the second edition of the Mental Health Atlas, consisting of revised and updated information on mental health from countries. The sources of information included the mental health focal points in the Ministries of Health, published literature and unpublished reports available to WHO. The results show that global mental health resources remain low and grossly inadequate to respond to the high level of need. In addition, the revised Atlas shows that the improvements over the period 2001 to 2004 are very small. Imbalances across income groups of countries remain largely the same. Enhancement in resources devoted to mental health is urgently needed, especially in low- and middle-income countries.

Defining bioethics as the rational use of dialogue in the formulation, justification, and application of ethical principles, with the aim ofgenerating good practices in research, clinical practice, and advocacy, this paper focuses on methods for bioethical deliberation relevantto psychiatry. Stressing that bioethics fuses the two main ethical traditions in Western thought, the deontological and the teleological, thepaper emphasizes the three conditions that any intervention, if considered in the context of bioethics, should fulfil: it should be appropriateto the problem at hand, it should be good (in the sense that it does good to those who receive it but also to those who perform it),and it should be just (in the sense that its outcomes can be generalized to the whole of society). Some implications of these notions for thepractice and teaching of psychiatry are presented.

Mental health care is in the process of transformation across the European Region, due to a combination of recognition of disease burden, poor treatment conditions and demand from clinicians and the public. This transformation affects the scope of mental health, increasingly including promotion and prevention, and the structure and process of care, shifting to community based delivery. Many psychiatrists are in leadership positions, able to influence policies and strategies. But their work is also seriously affected by the consequences of these policies. New roles and responsibilities of all members of a multi-disciplinary team need to be planned, and education and training have to be designed to prepare professionals to deal with expectations and demands. Psychiatrists face major challenges, since their complex roles are affected in multiple ways by the psychiatric and general health system. Some of these challenges can be addressed by the psychiatric profession and their partners, including patient and family organizations; others require wide ranging changes in attitude and system design.

In spite of recent clinical and research advances, an increased burden of mortality and morbidity related to stress and mental ill health can be noted, especially in European societies and populations undergoing stressful transitions and dramatic changes. A societal syndrome, consisting of depression, suicide, abuse, risk-taking and violent behaviour as well as vascular morbidity and mortality, can be observed, reflecting individual psychopathology related to disturbances of the serotonin metabolism as one of the oldest, most basic cerebral instruments of mankind to survive, to socialize, to cope with stress and danger. In a time where mental health professionals look for new and challenging identities, they have a tendency to abdicate from social psychiatric and public health activities in favour of more prestigious positions in brain research, genetics or advanced psychotherapy. A redefinition, reconceptualization and renaissance of social psychiatry seems timely and necessary, responding to the burden, advances and possibilities related to mental health we find today. It should proceed from the reductionism which often has characterized earlier psychosocial and social psychiatric approaches, utilize modern knowledge about neuroplasticity, psychoimmunology, neuropsychology and neurophilosophy, reflect the interaction between environment and structure, nature and nurture, and integrate different areas of knowledge in a holistic public mental health approach. Political decisions and societal solutions can be more or less in line with basic human preconditions. Consequences of failure to respect this already can be seen. A new awareness and responsibility-taking with regard to basic human ethological, physiological, psychological and existential conditions is needed and has to be concretized in innovative public mental health approaches.

This article reviews the impact of cultural factors on mental health of South Asian women. Marked gender discrimination in South Asia has led to second class status of women in society. Their mobility, work, self-esteem and self-image, in fact their worth and identity, seem to depend upon the male members of a patriarchal society. Women's lack of empowerment and both financial and emotional dependence have restricted their self-expression and choices in life. This, along with family, social and work pressures, has a definite impact on women's mental health.

In order to contribute to reduce the stigma related to schizophrenia and to improve clinical practice in the management of the disorder, the Japanese Society of Psychiatry and Neurology changed in 2002 the old term for the disorder, "Seishin Bunretsu Byo" ("mind-split-disease"), into the new term of "Togo Shitcho Sho" ("integration disorder"). The renaming was triggered by the request of a patients' families group. The main reasons for the renaming were the ambiguity of the old term, the recent advances in schizophrenia research, and the deep-rooted negative image of schizophrenia, in part related to the long-term inhumane treatment of most people with the disorder in the past. The renaming was associated with the shift from the Kraepelinian disease concept to the vulnerability-stress model. A survey carried out seven months after renaming in all prefectures of Japan found that the old term had been replaced by the new one in about 78% of cases. The renaming increased the percentage of cases in which patients were informed of the diagnosis from 36.7% to 69.7% in three years. Eighty-six percent of psychiatrists in the Miyagi prefecture found the new term more suitable to inform patients of the diagnosis as well as to explain the modern concept of the disorder. The Japanese treatment guideline for "Togo Shitcho Sho" was developed in 2004 under the framework of the vulnerability-stress model.

The characteristics of a good psychiatrist practising in the UK health services have been described in policy but not in practice. We set out to determine what key characteristics are required for an individual to be identified as a good psychiatrist to become a member of the Royal College of Psychiatrists. A postal survey of all clinical tutors responsible for psychiatric training in the UK and Eire was carried out. These tutors are approved by the Royal College of Psychiatrists. 113 tutors responded (out of 163, 69.3% return). The most important identified characteristic was overall competency in diagnosis, management and investigations (98%) and the least desirable was ability to appraise staff (13%). With recent changes in training and assessment in the UK, further surveys of this kind are indicated to understand the trainers' views, and should be extended also to trainees.

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.

This paper summarizes the findings for the European Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. The article presents a description of the region, an overview of mental health policies and legislation, a summary of relevant research in the region, a precis of community mental health services, a discussion of the key lessons learned, and some recommendations for the future.