What to do to promote mental health of the society.

BACKGROUND: According to the last existing documents, the prevalence rate of mental disorders is about 20% which is considered to be 14% of all country's burden of disease. In the fifth economical, social, and cultural development plan of the country in accordance with the 20 year vision, "healthy human being" and "comprehensive health" approaches and also improving of mental health indicators are emphasized. Aim of study was preparing national policy and interventions for promoting mental health.
METHODS: Using secondary data, analytical review of country's mental health programs, recommendations of WHO, descriptive situation of mental health and its trend during the last decade were drafted and a group of experts and stakeholders was formed following a sound stakeholder's analysis. After three Focus Group Discussions (FGDs), main points of the meetings, influencing factors of present situation, and oncoming strategies were agreed upon.
RESULTS: Based on different studies and the experts' opinions, the prevalence of mental disorders in the last decade has increased. Coverage of mental health programs in two last decades in the best could be equal to rural population. Urban areas have been deprived of these services. Analysis of mental health system of the country shows that internal environment is weak and the external one is concede to be in threat. Eight principal challenges in country's mental health are considered.
CONCLUSION: Improving current situation requires increasing internal capacity of mental health system and developing inter-sectoral cooperation. During next five years, the Ministry of Health, Iran should mainly focus on improving mental health services particularly in urban and peri-urban areas, promoting mental health literacy of different groups and minimizing mental health risk factors.

Introduction

Prevalence rate of mental disorders, based on the last documents, is about 20% (1) which constitutes nearly 14% of Iran burden of disease (2). WHO believes that the mental health is not merely absence of mental disorders. It includes, however, many other determinants. In case they are taken into account, burden of social-mental problems will be more evident (3). There are reasons that reminding necessity of investment of policy makers and planners on mental health such as (4):

Direct economical expenses (financial burden of diagnosis, treatment, rehabilitation, and prevention) and indirect costs (reduction of personal abilities, decrease of society’s productive force, family burden) of diseases and mental disorders are exorbitant.

Following prevalence of mental disorders, different kinds of social damages and accordingly security and legal (forces and judicial) expenses increase.

Some statistics indicate that highest rate of disablement and decrease of society’s productive force is related to mental diseases, which in turn leads to lower achievement rate in attaining social development goals.

Increase of poverty and consequently mental disease burden constitute a vicious cycle.

Increase of working burden of health care providers, slowing cure of physical diseases because of lower compliance among the mentally ill patients

Prevalence of mental disorders, causes human rights violation (this item is both cause and effect)

More attainment in dealing with physical health objectives such as: reduction of infants mortality rate because of higher achievements in curing postpartum depression, reduced rate of HIV/AIDS in age group 17–24 following reduction of high risk sexual behaviors or drug abuse, more compliance and acceptance of patients to treat their physical diseases such as diabetes, hypertensions, cancer, and tuberculosis.

A mentally ill patient and his family are exposed to social stigmas and discriminations which stimulates their isolation feeling and limited social incorporation, in a word leads to reduction of individual, family, and society capital. In fact social capital is both cause and effect.

Mental and physical diseases such as AIDS, injuries and traffic accidents have synergic effects.

In the fifth economical, social, and cultural development plan of the country, in accordance with the 20 year vision, approaches like “healthy human being”, “comprehensive health” and also improving mental health indicators particularly among school children and comprehensive campaign against narcotics and attempting to operate public policies for narcotic campaign in the next decade which is called development and justice, have been emphasized (5).

On the basis of the available reports of WHO, risk factors of mental health including improper development of early childhood, improper marriage reproduction, violence, violating citizenship rights, parents having mental disorders, inappropriate and inattentive school and, weak life skills and parenting, low social capital, unsafe social behaviors and additionally decline in morals (as the most pivotal factor of mental health), cause most of the mental disorders and require support and developing inter-sectoral cooperation (6, 7) .

According to the multiplicity of influencing factors on mental health, it is clear that responsibility of supplying mental health services of a society is far from a single system such as the Ministry of Health or its dependant universities. It does require cooperation and coordination of many others. In such a condition, the way to agree upon the influencing factors on mental health and interventions would be different as well; and requires a great deal of inter sectoral effort and cooperation of all different sectors. The Ministry of Health has to take three roles of knowledge broker, advocacy and leadership against other organizations in this respect (8).

Considering that organizing the comprehensive scientific plan and to make the fifth plan are set in agenda of policy making council of Ministry of Health, an urgent and fundamental decision on how to promote mental health interventions and to manage it in an integrated package seems very necessary. Formulating policies of mental health promotion is quite essential so aim of study was preparing national policy and interventions for promoting mental health. It is expected that after approving and employing these strategies, a common language is created among various stakeholders to manage mental health, feeling the program ownership is increased, and stability of mental health programs is guaranteed despite managers’ replacement.

Methods

This is a descriptive and analytical study which uses three methods for collecting data. The first is reviewing all secondary data published in relation with mental health to explain mental health status and its trend in last decade: based on this review indices of mental health at the effect level of the results chain including effect, outcome, output, process, and input, were drawn. Second one is reviewing and analyzing country’s mental health situation to accomplish meeting the administrator and experts of Mental Health Office were interviewed, and all documents and programs which were implemented or examined, were collected, studied, and analyzed. These documentaries included annual reports of Mental Health Office, program evaluation report, leading (steering) documents related to mental health, previous strategic plan documentaries, documentary of mental health programs, and study reports and collected statistics and the third one is reviewing WHO reports on mental health next to 2000 in order to find risk factors of mental health, strategies, and recommendations. Based on acquired data and considering the model for improving mental health services (9) “managing system of mental health” in both external and internal environments were analyzed with following segments:

Segment one : internal environment includes three components .The first component is stewardship for mental health consisted of program existence, intra-sectoral coordination, advocacy, supervision and regulations, mentally ill patients rights, inter-sectoral cooperation and community participation .The second one is resources comprising of financing, human resource, information and, medicine in mental health and finally health promotion services, prevention, treatment and rehabilitation

Segment two: external environment in two parts of far and near environments. The close environment, state of coordination and attitude of stakeholders and in the far one, situation of economical, social, political, technological, international, and environmental factors were analyzed and drafted.

Using data collected by the three aforementioned methods, drafting was taken place in three sections including present status (mental health indices, their trends, strength and weaknesses of country’s mental health management system and analysis of current programs), risk factors affecting current status of mental health; and interventions in three different preventive levels.

After analyzing country’s stakeholders, a group of experts and main stakeholders was formed. In selection and analysis of stakeholders, two main criteria were considered: their statutory position and their influence to promote mental health. On the whole, stakeholders were defined as decision makers and policy making authorities, ministries and organizations, scientific associations, experts, international organizations and ministry of health. They initiated working as members of technical leadership committee by order of Health Minister. After three sessions of FGDs, the current situation, main problem areas in mental health, contributing factors in present situation, and forthcoming strategies were reviewed and finalized. Simultaneously, in order to receive universities comments on the way to complete strategies, university experts on mental health participate during a one-day national meeting.

Results

In accordance with 2001 report of WHO, mental disorders, injuries and AIDS explain 13%, 12%, and 6% of world’s DALY(disability-adjusted life year) respectively. Out of total disease burden, mental diseases constitute 33% of YLD (years lived with disability) and depression is responsible for 12.15% of YLD, namely has the third place among accounted reasons. It is predicted that burden of mental diseases will be accelerated until 2020.

In 1999 mental health research (with a sample of 35000 people), prevalence rate of mental disorders in a population over 15 years have been estimated 21%, in which depression and anxiety had higher prevalence rate. Prevalence of mental disorders varied from 11.6% in Yazd province to 39.1% in Chaharmahal & Bakhtiari. Other studies show nearly the same amounts in mental disorders prevalence. Total number of successful suicides reported to Ministry of Health in 2004 was 3235 cases, and is calculated as 6.5 in 100000. This amount varied from 0.4 in Qom Province to 24.4 in Lorestan Province. Based on the collected information from mental health office, rate of attempted suicide and completed suicides during first decade of 2000 from 3823 suicide attempt and 279 fatal one has reached to 48800 suicide attempts and 1383 lethal suicide in 2009.

Burden of Disease Study in Iran indicates that mental disorders constitute 10.25% of whole disease burden (including substance related disorders to be 14.5%). Three first causes of mental disorders are depression (26% of mental disorders burden), addiction (24% of mental diseases burden), and bipolar disorders (12% of mental disorders burden).

When consider other mental disorders including drug abuse, according to carried out studies, burden of mental disorders take the second place after cardio-vascular disease and unintentional accidents commonly setting at the first. Compared with other diseases, depression in women creates more burdens.

Based on accomplished study in 1999 respecting mental patients’ referral path to specialized hospitals, it was cleared that 84.3% of studied people referred to physicians and clinics at first and 14.5% had chosen traditional therapists and alternative remedies and 42.5% of them referred to healers which give written prayers to patients. With reference to world trends and also accelerated development trend in different parts of the country, particularly in industry, mental health experts believe that trend and burden of mental diseases during last 10 years (after the last national survey) have been increased; however this fact have to be proved with the latest mental health survey of the country which was started in 2010 and its results will be published in a few months. Recent studies such as Urban HEART Study in Tehran in 2009 show that prevalence of probable psychiatric disorders among citizens of Tehran has been 34.2% in average with significant differences in various regions. Some mental health facilities/resources indicators are as follows (Table 1).

Table 1:

Mental health-related facilities and human resources based on available data of Ministry of Health

Mental health resources	Total No.	Mental health resources	Number in whole country
Number of psychiatric beds	12000 with unequal distribution	Physician’s private clinics	500
Number of psychiatric emergency beds	248 (Nothing in 17 provinces)	Psychiatrist	About 1000 (41% settled in Tehran)
Number of children psychiatry beds	229 (Nothing in 23 provinces)	Clinical psychology	174 (47 with doctorate degree)
Single-specialty psychiatric hospital	34 (9 province do not have any)	Trained General Practitioner (GP)	3800
General hospitals with psychiatric ward	76	Psychiatry-trained GP	200
Outpatient Clinics	115	Women Health Volunteers	100/000
Psychiatric clinic	45	Behvarzes and health Technicians	5000

Evaluating country’s mental health integration with PHC networks shows that Behvarzes are well informed about mental health basic principles; general practitioners cure 80% of patients who come to rural health centers and refer 20% of them to specialists.

Exploring efficiency of medical consultations and follow-up of psychiatric patients at home leads to less re-admittance up to 30 to 90% and lower costs between 2.5 up to 7.5 times.

Based on performance reports of Ministry of Health and Medical Education current interventions on mental health promotion are divided into four groups as: a) under study and formulation, b) pilot, c) implementing at country level, and d) evaluating an ended phase”. Primary analysis of mental health programs specifies that a limited number of programs were nationwide and most of programs are at pilot or study and formulation stage and are not evaluated and decided to be established throughout the country.

Reviewing management of mental health system with SWOT analysis suggests that currently in most cases, internal environment is weak from three components of stewardship, resources, and service provision point of view; and external environment for mental health system to attain goals, is in threat conditions both in near and far environments. Reviewing structure of mental and social health and drug abuse office shows that present structure which has limited the office to advisors of health and medical deputies; is not adequate at all to deal with the burden of mental health diseases in our country. This structure needs to change proportionately with designed program at institutional level of ministry and universities.

Reviewing available documents of strategic programs and mental health policies reveals that although in the last ten years some policies were made to promote mental health and pivotal points and key interventions, but it has not followed by distinct operations, work distribution, timetabling and financial-political commitment of stakeholders.

Analysis of mental health programs and policies in two previous decades clear that in order to improve situation and promotion of society’s mental health, different interventions were not applied, for example community participation inter-sectoral cooperation, social marketing for healthy mental behaviors and social stigmas, media and law were minimally used.

On the basis of analyses, eight key topics and challenges of mental health promotion are as follows:

Low sensitivity of supreme policy makers and decision makers even within the Ministry of Health and universities

Low literacy of people on mental health

Poor and inadequate programs of prevention (particularly in terms of social determinants of health)

Low intro-sectoral coordination and inter-sectoral cooperation

Mental health programs are inadequate in their dosage and coverage

Poor quality and in consistency in taking care of chronic diseases

Indistinct mental health care system in urban areas

Poor structure, system process, and resources (human resource, information, and budget) of mental health system.

Reviewing world recommendations and summing up experts’ ideas throughout this study show that Ministry of Health have to devise and perform some interventions in coming five years in order to make profound changes in people’s awareness in relation to mental health and through proper advocacy among organizations, make them take their role and contribution in promoting mental health. The intervention package requires in three preventive levels (Table 2).

Table 2:

Mental health promotion interventions

Fundamental Interventions
First Level Prevention	1. Forming an advisor and advocacy group for influencing healthy public policies (particularly in mental health) 2. Determining role of governmental organizations, nongovernmental and private sections (NGOs and Islamic Councils) in promoting mental health 3. Approving mental health law and monitoring their implementation 4. Develop and implement a comprehensive program for preventing social violence 5. Redesigning mental health programs in standard form of “health programs” 6. Develop and implement mental health promotion program for children, adolescents, and pregnant women 7. Composing charter of “Iranians’ mental health” 8. Continuance and completion of mental health integration program into PHC networks and other routine programs 9. Designing and applying educational program of promoting knowledge and attitude of policy makers and senior managers of the country on the more priority areas of mental health 10. Formulating educational content of promoting spiritual, social, and mental health of students 11. Design and implement mental health promotion program in workplace 12. Advocacy and cooperation to use appropriate language and method of promoting people’s knowledge on mental health 13. Performing classified and targeted programs in “mental health week” 14. Designing and implementing mental health promotion program for health system workers
Second level prevention	15. Reviewing structure for provision of mental health services 16. Developing clinical practice guidelines for prevention, care, and referral of the mentally-ill patients in family physician program 17. Development program of mental health specialty services within the country’s medical care system 18. Planning and practicing screening package and taking care of mentally-ill patients in 19. Develop and implement service package for mental health in peri-urban areas 20. Formulating and establishing program for promoting psychiatric emergency services 21. Planning and conducting rehabilitation programs including promoting mental health proficiency among all medical care groups 22. Making community-oriented mental health centers and deploying or merging it in PHC networks 23. Implementing programs to encourage hospitals to allocate 10% of hospital beds and the psychosomatic wards 24. Designing and implementing monitoring systems to oversee the mental health services in private sector 25. Establishing a hospital particularly for criminals having psychiatric disorders 26.
Third level Prevention	27. Formulating or reviewing mental patients support package 28. Planning and practicing advocacy programs to increase insurance coverage to take care of chronic mentally-ill patients 29. Designing and implementation rehabilitating service package for psychiatric patients 30. Formulating and notifying protocol of self-aid groups specified to mentally-ill patients

Discussion

Although available studies are not sufficient enough to show increasing trend of incidence, prevalence, and burden of mental diseases, experts and stakeholders believe those diseases have a rising trend; previous and current interventions do not have adequate effectiveness and coverage and need urgent measures while in developing countries, 90% of the affected have no access to proper treatment. Reviewing necessary interventions for “mental health promotion” in WHO (10) suggestions indicate that planning and implementing various interventions are necessary and inevitable at following three levels:

Primary prevention: preventing incidence of mental disorders

Secondary prevention: early recognition and timely treatment of mental disorders

Tertiary prevention: rehabilitation of the mentally-ill patients to reduce occurrence of any defect or disability caused by disease or disorder

Even though declining burden of mental diseases are emphasized the third and forth development plans (11) yet, failure of lawmakers’ objectives must be primarily searched in political will of “administrators in executing law” and “legislators in supervision”. Meanwhile, pathology of country’s five-year development plans reveal that performing national decisions in general requires promoting administrators’ knowledge in relation with “establishment and executing programs and policies” (12). Basirnia et al. suggest, overall the study’s results on prevalence of mental disorders among students are not adequate for determination of incidents rate, and needs periodic studies(13); it is true in other mental health indices and demands setting up observatory system of mental health throughout the country.

Changing of population profile during last three decades, migration of rural inhabitants to towns or peri-urban areas of large cities and also analysis of mental health program coverage in Iran shows that there is underlying deficiency in provision of mental health services in urban areas (14, 15).

Improving current situation needs increasing internal capacity of mental health system and developing intersectoral cooperation (including community participation). According to current study in coming five years three basic strategies have to form main operations of Ministry of Health: improving actual status of mental health services particularly in cities and slum areas, promoting mental health knowledge of different groups; and investing for reduction of mental health risk factors.

Approving strategies by policy making council within the Ministry of Health, High Council for Health and Food Security, to communicate the implementation protocol with universities, are the first steps to settle the national plan. It should be followed through signing cooperation agreements between different sectors and Ministry of Health, securing project management system in mental health office, and monitoring products.

Applying collective wisdom and increasing program ownership, evaluating strengths and weaknesses among mental health staff, developing a documentary for inter-sectoral advocacy, and increasing resources, are considered four important functional objectives in the course of formulating those policies.

Although these characteristics owe increase of organizational learning in Ministry of Health for designing and settling strategic programs, one should not dismiss the risk of forgetting programs after substitution of managers. It is necessary to design and perform all attempts to institutionalize the program.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.