Over the past half century, the model for mental health care has changed from the institutionalization of individuals suffering from mental disorders to a community care approach backed by the availability of beds in general hospitals for acute cases. This change is based both on respect for the human rights of individuals with mental disorders, and on the use of updated interventions and techniques. A correct objective diagnosis is fundamental for planning individual care and choice of appropriate treatment. The earlier a proper course of treatment starts, the better the prognosis. Appropriate treatment of mental and behavioural disorders implies the rational use of pharmacological, psychological and psychosocial interventions in a clinically meaningful and integrated way. The management of specific conditions consists of interventions in the areas of prevention, treatment and rehabilitation.
THE SHIFTING PARADIGM
The care of people with mental and behavioural disorders has always reflected prevailing social values related to the social perception of mental illness. Through the ages, people with mental and behavioural disorders have been treated in different ways (see Box 3.1). They have been given a high status in societies which believe them to intermediate with gods and the dead. In medieval Europe and elsewhere they were beaten and burnt at the stake. They have been locked up in large institutions. They have been explored as scientific objects. And they have been cared for and integrated into the communities to which they belong.
In Europe, the 19th century witnessed diverging trends. On one hand, mental illness was seen as a legitimate topic for scientific enquiry; psychiatry burgeoned as a medical discipline, and people with mental disorders were considered medical patients. On the other hand, people with mental disorders, like those with many other diseases and undesirable social behaviour, were isolated from society in large custodial institutions, the state mental hospitals, formerly known as lunatic asylums. These trends were later exported to Africa, the Americas and Asia.
During the second half of the 20th century, a shift in the mental health care paradigm took place, largely owing to three independent factors.
* Psychopharmacology made significant progress, with the discovery of new classes of drugs, particularly neuroleptics and antidepressants, as well as the development of new forms of psychosocial interventions.
* The human rights movement became a truly international phenomenon under the sponsorship of the newly created United Nations, and democracy advanced on a global basis, albeit at different speeds in different places (Merkl 1993).
* Social and mental components were firmly incorporated in the definition of health (see Chapter 1) of the newly established WHO in 1948.
These technical and sociopolitical events contributed to a change in emphasis: from care in large custodial institutions, which over time had become repressive and regressive, to more open and flexible care in the community.
The failures of asylums are evidenced by repeated cases of ill-treatment to patients, geographical and professional isolation of the institutions and their staff, weak reporting and accounting procedures, bad management, ineffective administration, poorly targeted financial resources, lack of staff training, and inadequate inspection and quality assurance procedures. Also, the living conditions in psychiatric hospitals throughout the world are poor, leading to human rights violations and chronicity. In terms of absolute standards, it could be argued that conditions in hospitals in developed countries are better than living standards in many developing countries. However, in terms of relative standards -- comparing hospital standards with general community standards in a particular country -- it is fair to say that the conditions in all psychiatric hospitals are poor. …