Why a global edition of Psychiatric Times? The needs of the world's mentally ill are great; the barriers to effective treatment, extensive; and the availability of resources, limited. Still, the opportunities for international collaboration, scientific synergy and significant progress are many. 

A trusted and well-read publication for mental health care professionals in the United States for more than 20 years, Psychiatric Times believes it can contribute to closing the gaps between the current global mental health situation and the provision of quality care for patients, whether in urban centers or remote villages. 

The welcome increase in Internet usage throughout the world (e.g., Internet access is available in all African capital cities) permits new modes of scientific exchange. In anticipation, we have made major improvements on our Web site, such as enabling mental health care professionals worldwide to access the full-text of articles in this global edition. 

We seek to facilitate global dialogues and information dissemination on issues such as mental health care policy and legislation, classification and diagnosis of mental disorders, research findings, clinical advances, treatment protocols, and prevention initiatives. All of this is being done with recognition that developing and developed countries can assist each other. Already, those in the developing countries are benefiting from the transmission of scientific technology, while those in developed countries are benefiting from knowledge of psychoactive herbal medicines used by traditional healers.

In this introduction to our first Global Watch edition, we offer glimpses of the global mental health burden, resource indicators and solution-oriented efforts. 

The World Health Organization (WHO) has warned that the international burden of mental disorders is enormous and growing. As of 1990, five of the 10 leading causes of disability worldwide--measured in years lived with a disability--were psychiatric conditions: unipolar depression, schizophrenia, bipolar disorders, alcohol dependence and obsessive-compulsive disorder (Murray and Lopez, 1996). It is expected that by 2020, major depression, which is already ranked fourth among the 10, will jump to second place (Brundtland, 2001a).

More than 450 million people worldwide suffer from mental and brain disorders. This includes 121 million people with depression, 24 million with schizophrenia and 37 million with dementia (WHO, 2001). Substance use disorders are a major challenge as well, with 140 million people dependent on or abusing alcohol (Brundtland, 2001a) and an estimated 5 million people injecting illegal drugs. The high prevalence of HIV infection among intravenous drug users has accelerated the spread of HIV/AIDS. 

Worldwide, nearly 1 million people commit suicide each year, and between 10 million and 20 million attempt it. The total number of youth suicides is increasing and in one-third of countries, suicide rates are higher among those under age 30 than in older age groups (Brundtland, 2001a, 2001b).

When viewed by region or country, the challenges become more specific. For example:

In Europe, about 41 million adults are estimated to abuse or are dependent on alcohol, yet 66% receive no treatment. For some European societies, the costs of alcohol abuse and dependence have been calculated to amount to 3% of their gross domestic product (WHO/Europe, 2001). 

In China, suicide among 15- to 34-year-olds is a leading cause of death; it is the number one cause of death among young women in rural areas (WHO, 2001). 

Epidemiological studies of mental health in Latin America have shown a consistent prevalence of 18% to 25% of mental disorders in communities and up to 48% in clinical settings (Alarcon, 2003). In the year 2000, 18 million people in the region suffered financially serious setbacks (unemployment, job dismissals, eviction, homelessness) as a result of clinically significant mental disorders. 

In 1959, WHO warned that efforts to have the mentally ill treated as other sick people who can be cured are likely to remain fruitless as long as the irrational fear of madness is not conquered and as long as all the influential members of the social hierarchy believe that mental health is the business of specialists rather than a concern of the whole community (Brundtland, 2001a).

Unfortunately, some 44 years later, Project Atlas, a database of WHO's Department of Mental Health and Substance Dependence, shows that 41% of 185 countries do not have a national mental health policy and 25% of 170 countries have no legislation on mental health care (WHO, 2002b). In fact, in 15% of countries worldwide mental health laws operate that are at least 40 years old (Thornicroft and Maingay, 2002). In addition, 44% of 184 countries do not have an epidemiological study or data collection system in mental health. 

Several societal factors hinder the development of mental health policies. Development of such policies in India, for example, has been circumscribed by an extremely limited number of mental health care professionals, a very limited mental health care service infrastructure (about 30,000 psychiatric beds for a billion population), problems of poverty and only 60% literacy (Murthy, 2003). 

Financing of mental health programs is a significant obstacle. The majority of Latin American countries "devote less than 2% of their total health budget to mental health," according to Alarcon (2003), "thus compounding a dismal picture already affected by everyday stress of all kinds (from massive internal migrations to a 'hidden epidemic' of domestic violence or from socio-political unrest to the ever-present risk of natural disasters)." 

Like funding, mental health resources are in short supply. Often, the resources and services are 1% to 10% of what is needed (Brundtland, 2001a). 

Throughout the world, a wide disparity exists in the type and numbers of the mental health workforce. In low-income countries, the median number of psychiatrists is 0.06 per 100,000 population and the median number of psychiatric nurses is 0.1 per 100,000. In high-income countries, the median number of psychiatrists is nine per 100,000 population and the median number of psychiatric nurses is 33.5 per 100,000 (WHO, 2001). Yet, nearly one-half of the world's population has access to one psychiatrist or less per 100,000 population; some countries (e.g., Bangladesh and Nigeria) may have access to less than one psychiatrist for every 1 million people (WHO, 2001). By comparison, the United Kingdom has one adult psychiatrist per 50,000 and the former Soviet Union has one psychiatrist per 10,000 to 20,000 (Jenkins, 2003). In Latin America, "the estimated figures of 1.6 psychiatrists, 2.7 psychiatric nurses, 2.8 psychologists and 1.9 social workers per 100,000 are far below those of Europe or the United States" (Alarcon, 2003). Some thought has been given to training traditional healers, the primary source of assistance for some 80% of rural inhabitants in developing countries, as case finders and referral sources (WHO, 2001).

Equally disturbing is the scarcity of psychotropic medications. According to WHO, at least one-fourth of countries do not have the three most commonly prescribed medications used to treat schizophrenia, depression and epilepsy at the primary care level. In Latin America, most of the countries have policies related to the supply and provision of psychotropic agents, yet more than one-third experience significant problems in implementing those policies (Alarcon, 2003). In many low-income countries, nurses are likely to be given the responsibility for prescribing and managing medicines, so it is important to make sure that they receive basic training and continuing education program support. 

Although it is widely accepted that community care generally is more effective, as well as more humane, than inpatient stays in mental hospitals, community care facilities have yet to be developed in about half the countries in the African, Eastern Mediterranean and Southeast Asian regions. In other regions, these facilities are absent in at least one-third of the countries. Nearly two-thirds of the world's psychiatric beds are still in psychiatric hospitals (WHO, 2002a).

As this brief introduction indicates, the challenges are daunting, but many organizations and governments are forging partnerships and initiating change. In 2001, WHO devoted both its annual health day and annual health report to mental health. The report reviewed the burden of mental disorders and the principal contributing factors, looking at service provision and planning, obstacles to treatment, prevention approaches, and recommendations for change. As a follow-up, WHO created the Mental Health Global Action Program, a five-year, $34 million program aimed at building strategic partnerships "for sustainable capacity building for mental health action in countries." The International Mental Health Consortium is working to identify reasons for the success and failure in mental health care reform and to develop the key elements of a national mental health care policy (Abas et al., 2003). The European Commission has produced a public health framework for mental health (Jenkins, 2003; Lavikainen et al., 2001). Through its involvement and collaboration on scientific meetings throughout the world and its many publications, the World Psychiatric Association promotes the dissemination of scientific information. 

Enormous progress is possible when health care professionals, international and national organizations, patients/consumers, advocacy groups, governments and media commit to proactive strategies to secure real gains in mental health care. 

 Abas M, Baingana F, Broadhead J et al. (2003), Common mental disorders and primary health care: current practice in low-income countries. Harv Rev Psychiatry 11(2):166-173.
 

 Alarcon RD (2003), Mental health and mental health care in Latin America. World Psychiatry 2(1):54-56.
 

 Brundtland GH (2001a), Mental health in our world: the challenges ahead. Presented at the Council for Mental Health Seminar. Oslo, Norway/Dec. 11.
 

 Brundtland GH (2001b), Message from the director-general. In: The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva: WHO. 
 

 Jenkins R (2003), Supporting governments to adopt mental health policies. World Psychiatry 2(1):14-19.
 

 Lavikainen J, Lahtinen E, Lehtinen V (2001), Public health approach on mental health in Europe. Helsinki, Finland: Stakes.
 

 Murray CJ, Lopez AD, eds. (1996), The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020 (Global Burden of Disease and Injury, Vol. 1). Cambridge, Mass.: Harvard School of Public Health.
 

 Murthy RS (2003), Mental health policy: India-towards community mental health care.
 

 Thornicroft G, Maingay S (2002), The global response to mental illness. BMJ 325(7365):608-609 [see comments].
 

 WHO (2001), The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva: World Health Organization. Available at: 

www.who.int/whr2001/2001/main/en/contents.htm

 WHO (2002a), Mental health: new WHO country data show resources fall short of needs. Available at: 

 WHO (2002b), Project Atlas: Database. Available at: 

 WHO/Europe (2001), Press backgrounder on the World Health Report 2001. Mental Health: New Understanding, New Hope. Available at: 

www.health.fgov.be/WH13/krant/krantarch2001/kranttekstock1/011008m03who-europe.htm

Articles

According to the World Health Organization, five of the 10 leading causes of disabilities worldwide are psychiatric conditions. More than 450 million people worldwide suffer from mental and brain disorders, and nearly 1 million people commit suicide each year. Because of this, many health care organizations and governments are forging partnerships to combat the daunting talk of providing quality health care around the globe.

Mental Illness: Global Challenges, Global Responses

Suicide is a complex phenomenon that is observable, at varying rates, in every nation around the world. Often, self-suppressive events are influenced by the impact of ecological and environmental factors, social fabric, individual predispositions, and current circumstances--factors that may interact, co-depend and cumulate over time. Decades of scientific investigation also suggest that such causal factors interact profoundly with the contextual system of values, traditions and sources of support available to individuals. In fact, social and cultural variables have been found to amplify any biological and psychological predisposition to suicidal behavior, regardless of age and sex (De Leo et al., 2002). 

In many Latin and Asian countries, suicide among the elderly is an increasing phenomenon, compared to Anglo-Saxon nations, where rates have been declining substantially since the 1960s. From 1960 to 1989, important shifts in the elderly/youth ratio of suicides were also observed in countries such as Hungary, Lithuania and Latvia (Lester, 2001) and in Asian nations where marked increases in suicide among the elderly corresponded with declines in youth suicides (Gulbinat, 1995). During the same period, Gulbinat observed the opposite phenomenon in many Anglo-Saxon nations of the New World, such as Australia, New Zealand, Canada and the United States. However, not all Latin and Anglo-Saxon countries experienced changes to the age distribution of suicide rates in recent decades.

Many Asian nations have observed greater rates of suicide among older, rather than younger age groups, with elderly/youth suicide ratios as high as 8.7 in Japan, 7.3 in Hong Kong and 5.9 in Singapore (Pritchard and Baldwin, 2002). In particular, women of Asian nations exhibit significantly higher rates of suicide in older age compared to women residing in other countries, particularly Anglo-Saxon nations. Suicide among males age 75 and older in selected areas of mainland rural China are also the highest of all nations that report mortality data to the World Health Organization (WHO, 2003a).

Among Western countries, when the rank ordering of suicide rates for males and females are considered for successive age groups (Table 1 and Table 2), a prominent difference between New World Anglo-Saxon countries and Latin European countries is evident. For example, close Anglo-Saxon countries Australia and New Zealand have higher-ranking suicide rates among males and females in younger age groups (15 to 24, 25 to 34, 35 to 44, and 45 to 54) compared to Spain and Portugal, two contiguous Latin countries. In successively older age groups (65 to 74 and 75+), however, the rank ordering is reversed, and suicide rates among both males and females in such Latin nations are ranked much higher than the Anglo-Saxon countries mentioned. The same cultural pattern may be observed by considering the elderly/youth ratio of suicide in these Western countries (Table 3). From this, it can be seen that for both males and females in Anglo-Saxon countries (and females in Canada), the ratio of elderly/youth suicides approaches 1:1, whereas in Latin nations, the ratio is ranked much higher. For example, in Portugal, elderly males complete suicide more than 11 times as frequently as males age 15 to 24. 

It is not entirely understood why these differences among countries exist; however, the epidemiological trends mentioned lead to speculations that sociocultural, economic and religious factors may contribute to the phenomenon. It has been suggested that the progressive decline in suicide rates observed among the elderly in Anglo-Saxon countries over the last 30 years, particularly in the United States and among white males, may have come about through improved attitudes toward retiring; improved social services; and enhanced psychiatric care, greater economic security and greater sociopolitical activism for the elderly (De Leo, 1998). On the contrary, in most Latin countries, as well as in some Asian nations (e.g., Hong Kong), social changes and the collapse of traditional family structures may have contributed to increases in suicide rates in older age. In Asia, for example, industrialization and Westernization have retransformed traditional family life into nuclear family set-ups, which may confine many elderly once supported by the extended family in a state of social isolation. In the absence of formal support and education on coping with age, such sociocultural changes may combine to foster suicidality among the elderly. 

From the epidemiological data highlighted in Table 1, it is also evident that suicide rates in nations that are historically, culturally and linguistically alike experience similar rates of suicide in older age. For example, bordering nations Hungary, Slovenia and Austria report high rates of suicide across all age groups, and in older age, these countries occupy the three highest respective ranks among males 75 and older. It is likely that the similarities in suicide rates are attributable, to a significant extent, to shared sociocultural facets, including similar attitudes toward suicidal acts, style and norms of living, main values and beliefs, educational systems and the upbringing of children, problems with alcohol, and attitudes that contribute to the perception of the elderly as a traditionally high-risk population for suicide (Grad et al., 2001). 

Moreover, the cultural element of suicide in old age is revealed in studies of elderly immigrants to Hong Kong, the United Kingdom and Australia that suggest that the prevalence of suicide--particularly in elderly immigrants--is largely determined by their country of origin (Burvill, 1995; Raleigh and Balarajan, 1992; Yip et al., 2000).  

The impact of religious affiliation upon suicide in older age should also be considered. In a study by Koenig (1994), older people who practice their faith were found to have frequently lower rates of depression, alcoholism and hopelessness (factors that have been found to increase the risk of suicide in the elderly [Rifai et al., 1994]) than their non-religious counterparts. Moreover, religious communities may serve to moderate loneliness and isolation in late life by providing an active support network and meaningful voluntary work, which can enhance well-being and promote feelings of usefulness and purpose (Krause et al., 1992). The tendency for older aged women to be more religious than men, attend church more (Weaver and Koenig, 1996), and be more involved in relational activities may perhaps further influence the rates of elderly female suicide, which are lower than those for males in every country of the world. 

Despite the certain impact of social and cultural variables upon suicide rates in old age, limited cross-cultural data are available to definitively tease out the actual contribution of such factors and the impact of other dynamics such as psychopathology, personality traits, previous suicidal behavior, stressful life events and physical illness (Steffens and Blazer, 1999). Nevertheless, anti-suicide strategies in old age must take into account the concomitance of factors that contribute to suicide risk, including an awareness of cultural/traditional aspects. 

The mainstay of suicide prevention initiatives targeted toward the aged is predominantly founded on the early detection and treatment of psychiatric disorders, mainly depressive illnesses. Notwithstanding, approximately 75% of all elderly suicide victims suffer from some sort of psychiatric disorder at the time of their death, with affective disorders representing the most common diagnosis (Henriksson et al., 1995; Waern et al., 2002). However, targeting depression in old age as a main strategy for preventing suicide may not be feasible in a number of countries. For example, vast differences exist across cultures with regard to the way in which individuals with psychiatric illnesses are perceived and thus integrated into the community. In some regions of the world, individuals with psychiatric illnesses are ostracized, and, as a consequence, the likelihood that individuals may seek professional assistance in response to psychological problems can be sternly reduced. The effects of stigma on the acceptance of a diagnosed psychiatric disorder appear to be more significant among men compared to women (Reynolds and Kupfer, 1999). Moreover, in many developing nations, mental health issues--including suicide--are not considered to be a matter of priority on governmental agendas and, as a result, financial provisions required to improve clinical diagnostic techniques and treatment regimens for psychiatric disorders may not be available.  

The conceptualization of psychological distress across cultures and in older age may also highlight difficulties related to the detection of depression in the clinical domain. Cross-culturally, Latin Americans in general may be more likely to conceptualize psychiatric symptoms in physical or medical terms than Anglo-Americans (Canino, 1982; Jenkins, 1988). In addition, ideas about the nature of mental illness in non-industrialized countries are poorly differentiated from those about physical illness, and the concepts of both usually overlap with or include religious and magical concepts (Cooper and Sartorius, 1977). 

In any case, regardless of culture, elderly individuals are more likely to complain of somatic symptoms than of psychological distress. Geriatric depression can and frequently does amplify physical symptoms; however, many elderly patients may deny psychological symptoms of depression or reject the diagnosis due to the stigma attached to it (Reynolds and Kupfer, 1999). Accordinaly, physicians seem to be able to detect depressive symptomatology in only 20% of depressed elderly patients (Vasilas and Morgan, 1994), and as few as 8% of elderly individuals who commit suicide may be treated adequately with antidepressant agents prior to death (Pitkala et al., 2000). However, it is important to acknowledge that even if the ability of physicians to detect depressive symptoms among the elderly were to improve, more than antidepressant treatment would be needed to avert suicide. Recent findings have shown that even by treating with (a 70% efficacy index) all depressed people, the obtainable reduction in suicide rates would not be higher than 12% (Bertolote et al., in press). 

Coupled with these clinical realities is also the tendency for older individuals, particularly men, not to communicate suicidal ideation and intent. Thus, relying on the emergence of depressive symptoms and/or communication of suicidality by elderly patients as indicators of suicide risk, together with the expectation that antidepressant agents may single-handedly prevent suicide, would be naive. Evidently, inquiry into other domains (e.g., personality traits, recent life events and losses, presence of physical illnesses, comorbidity, loneliness and social isolation, involuntary retirement, financial difficulties) and a greater emphasis on the sociocultural facet of suicide in late life may provide appropriate clues to suicide risk and prevention. 

Suicide among the elderly is undoubtedly a complex phenomenon, and the difficulty in preventing suicide, regardless of cultural delineation, is apparent. Across cultures, suicide in older age is more prevalent in Latin and Asian countries, compared to Anglo-Saxon nations. In all countries, primary care physicians and mental health care professionals face a common dilemma in detecting symptoms of depression and suicidality among the elderly. Ideally, in order to prevent suicide in late life, complete consideration should be paid to both the personal characteristics and circumstances and the sociocultural milieu of an elderly person. 

With reference to large-scale suicide prevention strategies for the aged, those that are formulated globally and implemented across cultures ought to take into account the unique sociocultural, economic and political structure of countries and the way in which suicide rates may hinge upon these constitutions. Thus, preventive efforts within societies must be adapted in a way that is sensitive to the cultural elements of suicide.

 Bertolote JM, Fleishmann A, De Leo D et al. (in press), Mental disorders and suicide. Br J Psychiatry.


 Burvill PW (1995), Suicide in the multiethnic elderly population of Australia, 1979-1990. Int Psychogeriatr 7(2):319-333.


 Canino G (1982), The Hispanic woman: sociocultural influences on diagnoses and treatment. In: Mental Health and Hispanic Americans: Clinical Perspectives, Bercerra RM, Karno M, Escobar JI, eds. New York: Grune and Stratton.


 Cooper J, Sartorius N (1977), Cultural and temporal variations in schizophrenia: a speculation on the importance of industrialization. Br J Psychiatry 130:50-55.


 De Leo D (1998), Is suicide prediction in old age really easier? Crisis 19(2):60-61.


 De Leo D, Bertolote J, Lester D (2002), Self-directed violence. In: World Report on Violence and Health, Krug EG, Dahlberg LL, Mercy JA et al., eds. Geneva: World Health Organization,pp183-212.


 Grad OT, Kogoj A, Trontelji J (2001), Elderly suicide in Slovenia. In: Suicide and Euthanasia in Older Adults: A Transcultural Journey, De Leo D, ed. Seattle: Hogrefe and Huber Publishers, pp77-88.


 Gulbinat W (1995), The epidemiology of suicide in old age. In: Preventive Strategies on Suicide, Diekstra RFW, Gulbinat W, Kienhorst I, De Leo D, eds. Leiden, The Netherlands: World Health Organization, E.J. Brill.


 Henriksson MM, Marttunen MJ, Isometsa ET et al. (1995), Mental disorders in elderly suicide. Int Psychogeriatrics 7(2):275-286.


 Jenkins JH (1988), Ethnopsychiatric interpretations of schizophrenia illness: the problem of nervios within Mexican-American families. Cult Med Psychiatry 12(3):301-329.


 Koenig HG (1994), Aging and God. New York: Haworth Press.


 Krause N, Herzog AR, Baker E (1992), Providing support to others and well-being in later life. J Gerontol 47(5):300-311.


 Lester D (2001), Suicide among the elderly in the world: covariation with psychological and socio-economic factors. In: Suicide and Euthanasia in Older Adults: A Transcultural Journey, De Leo D, ed. Seattle: Hogrefe and Huber Publishers, pp1-20.


 Pitkala K, Isometsa ET, Henriksson MM, Lonnqvist JK (2000), Elderly suicide in Finland. Int Psychogeriatr 12(2):209-220.


 Pritchard C, Baldwin DS (2002), Elderly suicide rates in Asian and English-speaking countries. Acta Psychiatr Scand 105(4):271-275.


 Raleigh VS, Balarajan R (1992), Suicide levels and trends among immigrants in England and Wales. Health Trends 24:91-94.


 Reynolds CF 3rd, Kupfer DJ (1999), Depression and aging: a look to the future. Psychiatr Serv 50(9):1167-1172.


 Rifai AH, George CJ, Stack JA et al. (1994), Hopelessness in suicide attempters after acute treatment of major depression in later life. Am J Psychiatry 151(11):1687-1690.


 Steffens DC, Blazer DG (1999), Suicide in the elderly. In: The Harvard Medical School Guide to Suicide Assessment and Intervention, Jacobs DJ, ed. San Francisco: Jossey-Bass Publishers, pp443-462.


 Vasilas CA, Morgan HG (1994), Elderly suicides' contact with their general practitioner before death. Int J Am Geriatr Soc 9:1008-1009.


 Waern M, Runeson BS, Allebeck P et al. (2002), Mental disorder in elderly suicides: a case-control study. Am J Psychiatry 159(3):450-455.


 Weaver AJ, Koenig HG (1996), Elderly suicide, mental health professionals, and the clergy: a need for clinical collaboration, training, and research. Death Stud 20(5):495-508.


 WHO (2003a), Country reports and charts. Available at: 

www.who.int/mental_health/prevention/suicide/country_reports/en/

 WHO (2003b), Mortality database. Available at:

 Yip PSF, Callanan C, Yuen HP (2000), Urban/rural and gender differentials in suicide rates: east and west. J Affect Disord 57(1-3):99-106.

A cross-cultural comparison of suicide in old age, including a discussion of recent epidemiological trends in suicide rates. The authors also discuss the impact of social and cultural variables on the detection of depression and the formulation of suicide prevention strategies.

Psychiatric Times Vol 10 No 11

Mental Illness: Global Challenges, Global Responses

Culture and Suicide in Late Life