What is the Revolving Doors Agency?

Introduction

Formed on 17 August 1993, the Revolving Doors Agency (RDA), also known as Revolving Doors, is a charitable organisation in the United Kingdom which works across England and Wales.

Through research, policy and campaigning work, the organisation aims to improve services for people with multiple needs who are in repeat contact with the criminal justice system.

Vision

The vision of the organisation is that by 2025 there is an end to the revolving door of crisis and crime, when anyone facing multiple problems and poor mental health is supported to reach their potential, with fewer victims and safer communities as a result.

Activities

To fulfil its vision, Revolving Doors organises its work around three areas:

AreaDescription
Policy and CommunicationsWorking with policymakers in national and local government, across Whitehall and in local and regional authorities, to improve responses for the revolving doors group. This work is informed by their research, the work of the organisation’s service user forums and their partnership and development work across the country.
Service User InvolvementThe organisation operates a national service user forum and a young peoples’ forum. The Forums bring together individuals from different areas of the country who have experienced mental health and other problems and have had contact with the criminal justice system. The forums are designed to root the organizations work in the reality of people’s experiences.
Local Partnerships and DevelopmentRevolving Doors works with organisations and individuals across England and Wales to demonstrate solutions for the revolving doors group.

Definition

The revolving door group refers to the experiences of people who are caught in a cycle of crisis, crime and mental illness, whereby they are repeatedly in contact with the police and often detained in prison as well as being victims of crime themselves. This is a group that often has multiple problems for which they need the input of a wide range of agencies, including housing, drugs, mental health, and benefits. The mental health problems of the group are usually a core or exacerbating factor. Routinely, they fall through the gaps of existing mental health service provision, as their mental health problems are not considered sufficiently “severe” to warrant care from statutory services; but they are frequently excluded from mainstream services in the community, such as GPs and Housing Associations, on account of the perceived complexity of their needs and their often challenging behaviour. Consequently, the lack of support contributes to a downward spiral that brings people into contact with the criminal justice system. It is estimated that the number of individuals within the revolving door group is approximately 60,000 at any one time.

Organisation

Formation

In 1992 a report undertaken by NACRO (a social justice charity) and an ITV Telethon identified a group of people who were caught in a downward cycle of homelessness and found themselves in repeat contact with both the mental health and criminal justice system. This group was identified as the ‘revolving doors’ group, which subsequent research has estimated to include 60,000 people at any one time.

Following the publication of the report in 1993, the Revolving Doors Agency was established by some of the parties involved in the initial publication who sought to demonstrate new ways of working in these three areas of criminal justice, mental health and homelessness. The focus of the organisation was on the people who kept falling between the mainstream services in the community.

Initially, the organisation conducted research in prisons and police stations to identify the needs of the revolving doors group and establish the issues they faced.

In the late 1990s the organisation established a series of experimental services, called Link Worker Schemes, to test effective interventions for their target group. The schemes offered individuals practical and emotional support, assisting them to access appropriate services and to address the underlying causes of their offending behaviour. An independent evaluation conducted by the Home Office found that the scheme cut reoffending by 22%.

Following a strategic review in 2006, the organisation adjusted its focus to research, policy and campaigning work in relation to people who become stuck in a cycle of mental health problems and crime. The Link Worker Schemes were passed over to other voluntary sector providers.

Funding

The organisation is funded by charitable donations from individuals, grants from statutory bodies and applications to charitable foundations. Recent funders include the Big Lottery Fund, the Esmée Fairbairn Foundation, The Henry Smith Charity, the Paul Hamlyn Foundation, the Pilgrim Trust and Trusts for London. The organisation has previously received funding from Comic Relief.

Revolving Doors has also received pro-bono support from Clifford Chance who, in partnership with the University of Cambridge Pro Bono Society, assisted the organisation with additional research.

Governance

Revolving Doors is governed by a Board of Trustees who oversee the activities of the organisation, which itself is run by a team of nine members of staff who are supported by associates across the country. The organisation is a registered private company limited by guarantee, with no share capital, which means it is run for non-profit purposes. It is a recognised as a charity by the Charities Commission.

Partnerships

The organisation affiliates itself to the Criminal Justice Alliance, a coalition of 58 organisations involved in policy and practice across the criminal justice system, the Mental Health Alliance, a coalition of 75 organisations which aims to secure a better mental health legislation, and the Transition to Adulthood Alliance, which works to improve the opportunities and life chances of young people in their transition to adulthood, who are at risk of committing crime and falling into the criminal justice system.

Patrons

The current patrons of Revolving Doors are Lord David Ramsbotham GCB CBE (Former Chief Inspector of Prisons), the Rt Hon. Hilary Armstrong (Former Member of Parliament for North West Durham and Cabinet Minister for Social Exclusion and Duchy of Lancaster), Ian Bynoe (Former Acting Deputy Chair of the Independent Police Complaints Commission), Rose Fitzpatrick (Acting Assistant Commissioner for the Metropolitan Police), Professor John Gunn (Professor of Forensic Psychiatry at the University of Birmingham), Dru Sharpling CBE (London Director of the Crown Prosecution Service), His Honour Judge Fabyan Evans, Bharat Mehta OBE (Chief Executive of Trusts for London), Joe Simpson (Consultant) and Peter Wrench, Consultant and Writer, former Prison Service and Home Office Director.

Publications

Revolving Doors has published a number of works with a focus on the revolving doors group who have mental health problems within the criminal justice system, including a report on the financial impact of supporting women with multiple needs in the criminal justice system. This report established that an investment of £18 million per year England-wide in interventions could reduce the cost to the state by £384m over three years and almost £1 billion over five years.

In 2012, Revolving Doors Published Integrated Offender Management – Effective alternatives to short sentences. It also published Ending the Revolving Door – guidance for Police and Crime Commissioners.

Reception

Revolving Doors is widely regarded as one of the UK’s leading charities concerned with mental health and the criminal justice system.

In 2002 the organisation received two UK Charity Awards, which are given for outstanding achievements within the UK not-for-profit sector, in the category of Research, Advice and Support, as well as being the Overall Winner.

In 2006 the Revolving Doors Agency received an award from the Care Services Improvement Partnership, part of the Care Services Directorate at the Department of Health, for their Link Worker Scheme in the London Borough of Islington. The same year, the organisation was also highly commended by the Centre for Social Justice.

In 2010, Neighbourhood Link, a scheme in the Islington developed in partnership by St. Mungo’s and the Revolving Doors Agency, was highlighted as evidence of good-practice by the Cabinet Office. The scheme helps people with multiple and complex needs who are either involved in crime or at risk of becoming involved in crime and becoming homeless. As a result of the project, contact with the police amongst the users has fallen from 31% to 9%.

An Overview of Global Mental Health

Introduction

Global mental health is the international perspective on different aspects of mental health.

It is ‘the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide’. There is a growing body of criticism of the global mental health movement, and has been widely criticised as a neo-colonial or “missionary” project and as primarily a front for pharmaceutical companies seeking new clients for psychiatric drugs.

In theory, taking into account cultural differences and country-specific conditions, it deals with the epidemiology of mental disorders in different countries, their treatment options, mental health education, political and financial aspects, the structure of mental health care systems, human resources in mental health, and human rights issues among others.

The overall aim of the field of global mental health is to strengthen mental health all over the world by providing information about the mental health situation in all countries, and identifying mental health care needs in order to develop cost-effective interventions to meet those specific needs.

The Global Burden of Disease

Mental, neurological, and substance use disorders make a substantial contribution to the global burden of disease (GBD). This is a global measure of so-called disability-adjusted life years (DALY’s) assigned to a certain disease/disorder, which is a sum of the years lived with disability and years of life lost due to this disease within the total population. Neuropsychiatric conditions account for 14% of the global burden of disease. Among non-communicable diseases, they account for 28% of the DALY’s – more than cardiovascular disease or cancer. However, it is estimated that the real contribution of mental disorders to the global burden of disease is even higher, due to the complex interactions and co-morbidity of physical and mental illness.

Around the world, almost one million people die due to suicide every year, and it is the third leading cause of death among young people. The most important causes of disability due to health-related conditions worldwide include unipolar depression, alcoholism, schizophrenia, bipolar depression and dementia. In low- and middle-income countries, these conditions represent a total of 19.1% of all disability related to health conditions.

Mental Health by (Select) Country

Africa

Mental illnesses and mental health disorders are widespread concerns among underdeveloped African countries, yet these issues are largely neglected, as mental health care in Africa is given statistically less attention than it is in other, westernised nations. Rising death tolls due to mental illness demonstrate the imperative need for improved mental health care policies and advances in treatment for Africans suffering from psychological disorders.

Underdeveloped African countries are so visibly troubled by physical illnesses, disease, malnutrition, and contamination that the dilemma of lacking mental health care has not been prioritised, makes it challenging to have a recognised impact on the African population. In 1988 and 1990, two original resolutions were implemented by the World Health Organisation’s (WHO) Member States in Africa. AFR/RC39/R1 and AFR/RC40/R9 attempted to improve the status of mental health care in specific African regions to combat its growing effects on the African people. However, it was found that these new policies had little impact on the status of mental health in Africa, ultimately resulting in an incline in psychological disorders instead of the desired decline, and causing this to seem like an impossible problem to manage.

In Africa, many socio-cultural and biological factors have led to heightened psychological struggles, while also masking their immediate level of importance to the African eye. Increasing rates of unemployment, violence, crime, rape, and disease are often linked to substance abuse, which can cause mental illness rates to inflate. Additionally, physical disease like HIV/AIDS, the Ebola epidemic, and malaria often have lasting psychological effects on victims that go unrecognised in African communities because of their inherent cultural beliefs. Traditional African beliefs have led to the perception of mental illness as being caused by supernatural forces, preventing helpful or rational responses to abnormal behaviour. For example, Ebola received loads of media attention when it became rampant in Africa and eventually spread to the US, however, researchers never really paid attention to its psychological effects on the African brain. Extreme anxiety, struggles with grief, feelings of rejection and incompetence, depression leading to suicide, PTSD, and much more are only some of the noted effects of diseases like Ebola. These epidemics come and go, but their lasting effects on mental health are remaining for years to come, and even ending lives because of the lack of action. There has been some effort to financially fund psychiatric support in countries like Liberia, due to its dramatic mental health crisis after warfare, but not much was benefited. Aside from financial reasons, it is so difficult to enforce mental health interventions and manage mental health in general in underdeveloped countries simply because the individuals living there do not necessarily believe in western psychiatry. It is also important to note that the socio-cultural model of psychology and abnormal behaviour is dependent on factors surrounding cultural differences. This causes mental health abnormalities to remain more hidden due to the culture’s natural behaviour, compared to westernised behaviour and cultural norms.

This relationship between mental and physical illness is an ongoing cycle that has yet to be broken. While many organisations are attempting to solve problems about physical health in Africa, as these problems are clearly visible and recognisable, there is little action taken to confront the underlying mental effects that are left on the victims. It is recognised that many of the mentally ill in Africa search for help from spiritual or religious leaders, however this is widely because many African countries are significantly lacking in mental health professionals in comparison to the rest of the world. In Ethiopia alone, there are “only 10 psychiatrists for the population of 61 million people,” studies have shown. While numbers have definitely changed since this research was done, the lack of psychological professionals throughout African continues with a current average of 1.4 mental health workers per 100,000 people compared to the global statistic of 9.0 professionals per 100,00 people. Additionally, statistics show that the “global annual rate of visits to mental health outpatient facilities is 1,051 per 100,000 population,” while “in Africa the rate is 14 per 100,000” visits. About half of Africa’s countries have some sort of mental health policy, however, these policies are highly disregarded, as Africa’s government spends “less than 1% of the total health budget on mental health”. Specifically in Sierra Leone, about 98.8% of people suffering from mental disorders remain untreated, even after the building of a well below average psychiatric hospital, further demonstrating the need for intervention.

Not only has there been little hands-on action taken to combat mental health issues in Africa, but there has also been little research done on the topic to spread its awareness and prevent deaths. The Lancet Global Health acknowledges that there are well over 1,000 published articles covering physical health in Africa, but there are still less than 50 discussing mental health. And this pressing dilemma of prioritizing physical health vs. mental health is only worsening as the continent’s population is substantially growing with research showing that “Between 2000 and 2015 the continent’s population grew by 49%, yet the number of years lost to disability as a result of mental and substance use disorders increased by 52%”. The number of deaths caused by mental instability is truly competing with those caused by physical diseases: “In 2015, 17.9 million years were lost to disability as a consequence of mental health problems. Such disorders were almost as important a cause of years lost to disability as were infectious and parasitic diseases, which accounted for 18.5 million years lost to disability,”. Mental health and physical health care, while they may seem separate, are very much connected, as these two factors determine life or death for humans. As new challenges surface and old challenges still have not been prioritised, Africa’s mental health care policies need significant improvement in order to provide its people with the appropriate health care they deserve, hopefully preventing this problem from expanding.

Australia

A survey conducted by Australian Bureau of Statistics in 2008 regarding adults with manageable to severe neurosis reveals almost half of the population had a mental disorder at some point of their life and one in five people had a sustained disorder in the preceding 12 months. In neurotic disorders, 14% of the population experienced anxiety and comorbidity disorders were next to common mental disorder with vulnerability to substance abuse and relapses. There were distinct gender differences in disposition to mental health illness. Women were found to have high rate of mental health disorders, and Men had higher propensity of risk for substance abuse. The Survey of Mental Health and Well-Being (SMHWB survey) showed families that had low socioeconomic status and high dysfunctional patterns had a greater proportional risk for mental health disorders. A 2010 survey regarding adults with psychosis revealed 5 persons per 1000 in the population seeks professional mental health services for psychotic disorders and the most common psychotic disorder was schizophrenia.

Bangladesh

Mental health disorder is considered a major public health concern and it constitutes about 13% of the Global Burden of disease and severe mental health disease may reduce each individual’s life expectancy by about 20%. Low and middle-income countries have a higher burden of mental health disorder as it is not considered as a health problem as other chronic diseases. Being a low-income country, in Bangladesh, mental health issues are highly stigmatised.

A community-based study in the rural area of Bangladesh in 2000-2001 estimated that the burden of mental morbidity was 16.5% among rural people and most were suffering from mainly depression and anxiety and which was one-half and one-third of total cases respectively. Furthermore, the prevalence of mental disorders was higher in women in large families aged 45 years.

Care for Mental Health in Bangladesh

A study conducted in 2008 stated that only 16% of patients came directly to the Mental Health Practitioner with a mean delay of 10.5 months of the onset of mental illness, which made them more vulnerable in many ways. 22% of patients went for the religious or traditional healer and 12% consulted a rural medical practitioner with the least delay of 2-2.5 weeks.

Canada

According to statistics released by the Centre of Addiction and Mental Health (CAMH) one in five people in Canada experience a mental health or addiction problem. Young people of ages 15 to 25 are particularly found to be vulnerable. Major depression is found to affect 8% and anxiety disorder 12% of the population. Women are 1.5 times more likely to suffer from mood and anxiety disorders. WHO points out that there are distinct gender differences in patterns of mental health and illness. The lack of power and control over their socioeconomic status, gender based violence; low social position and responsibility for the care of others render women vulnerable to mental health risks.[citation needed] Since more women than men seek help regarding a mental health problem, this has led to not only gender stereotyping but also reinforcing social stigma. WHO has found that this stereotyping has led doctors to diagnose depression more often in women than in men even when they display identical symptoms. Often communication between health care providers and women is authoritarian leading to either the under-treatment or over-treatment of these women.

Women’s College Hospital has a programme called the “Women’s Mental Health Programme” where doctors and nurses help treat and educate women regarding mental health collaboratively, individually, and online by answering questions from the public.

Another Canadian organisation serving mental health needs is CAMH. CAMH is one of Canada’s largest and most well-known health and addiction facilities, and it has received international recognitions from the Pan American Health Organisation and WHO Collaborating Centre. They do research in areas of addiction and mental health in both men and women. In order to help both men and women, CAMH provides “clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental health and addiction issues.” CAMH is different from Women’s College Hospital due to its widely known rehab centre for women who have minor addiction issues, to severe ones. This organisation provides care for mental health issues by assessments, interventions, residential programmes, treatments, and doctor and family support.

Middle East

Israel

In Israel, a Mental Health Insurance Reform took effect in July 2015, transferring responsibility for the provision of mental health services from the Ministry of Health to the four national health plans. Physical and mental health care were united under one roof; previously they had functioned separately in terms of finance, location, and provider. Under the reform, the health plans developed new services or expanded existing ones to address mental health problems.

United States

According to the WHO, in 2004, was depression is the leading cause of disability in the United States for individuals ages 15 to 44. Absence from work in the US due to depression is estimated to be in excess of $31 billion per year. Depression frequently co-occurs with a variety of medical illnesses such as heart disease, cancer, and chronic pain and is associated with poorer health status and prognosis. Each year, roughly 30,000 Americans take their lives, while hundreds of thousands make suicide attempts (Centres for Disease Control and Prevention). In 2004, suicide was the 11th leading cause of death in the United States (Centres for Disease Control and Prevention), third among individuals ages 15-24. Despite the increasingly availability of effectual depression treatment, the level of unmet need for treatment remains high. By way of comparison, a study conducted in Australia during 2006 to 2007 reported that one-third (34.9%) of patients diagnosed with a mental health disorder had presented to medical health services for treatment. The US has a shortage of mental healthcare workers, contributing to the unmet need for treatment. By 2025, the US will need an additional 15,400 psychiatrists and 57,490 psychologists to meet the demand for treatment.

Treatment Gap

It is estimated that one in four people in the world will be affected by mental or neurological disorders at some point in their lives. Although many effective interventions for the treatment of mental disorders are known, and awareness of the need for treatment of people with mental disorders has risen, the proportion of those who need mental health care but who do not receive it remains very high. This so-called “treatment gap” is estimated to reach between 76-85% for low- and middle-income countries, and 35-50% for high-income countries.

Despite the acknowledged need, for the most part there have not been substantial changes in mental health care delivery during the past years. Main reasons for this problem are public health priorities, lack of a mental health policy and legislation in many countries, a lack of resources – financial and human resources – as well as inefficient resource allocation.

In 2011, the WHO estimated a shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries. The annual wage bill to remove this health workforce shortage was estimated at about US$4.4 billion.

Interventions

Information and evidence about cost-effective interventions to provide better mental health care are available. Although most of the research (80%) has been carried out in high-income countries, there is also strong evidence from low- and middle-income countries that pharmacological and psychosocial interventions are effective ways to treat mental disorders, with the strongest evidence for depression, schizophrenia, bipolar disorder and hazardous alcohol use.

Recommendations to strengthen mental health systems around the world have been first mentioned in the WHO’s World Health Report 2001, which focused on mental health:

  • Provide treatment in primary care.
  • Make psychotropic drugs available.
  • Give care in the community.
  • Educate the public.
  • Involve communities, families and consumers.
  • Establish national policies, programs and legislation.
  • Develop human resources.
  • Link with other sectors.
  • Monitor community mental health.
  • Support more research.

Based on the data of 12 countries, assessed by the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), the costs of scaling up mental health services by providing a core treatment package for schizophrenia, bipolar affective disorder, depressive episodes and hazardous alcohol use have been estimated. Structural changes in mental health systems according to the WHO recommendations have been taken into account.

For most countries, this model suggests an initial period of investment of US$0.30 – 0.50 per person per year. The total expenditure on mental health would have to rise at least ten-fold in low-income countries. In those countries, additional financial resources will be needed, while in middle- and high-income countries the main challenge will be the reallocation of resources within the health system to provide better mental health service.

Prevention

Prevention is beginning to appear in mental health strategies, including the 2004 WHO report “Prevention of Mental Disorders”, the 2008 EU “Pact for Mental Health” and the 2011 US National Prevention Strategy. NIMH or the National Institute of Mental Health has over 400 grants.

Stakeholders

World Health Organization (WHO)

Two of WHO’s core programmes for mental health are WHO MIND (Mental health improvements for Nations Development) and Mental Health Gap Action Programme (mhGAP).

WHO MIND focuses on 5 areas of action to ensure concrete changes in people’s daily lives. These are:

  • Action in and support to countries to improve mental health, such as the WHO Pacific Island Mental Health network (PIMHnet).
  • Mental health policy, planning and service development.
  • Mental health human rights and legislation.
  • Mental health as a core part of human development.
  • The QualityRights Project which works to unite and empower people to improve the quality of care and promote human rights in mental health facilities and social care homes.

Mental Health Gap Action Programme (mhGAP) is WHO’s action plan to scale up services for mental, neurological and substance use disorders for countries especially with low and lower middle incomes. The aim of mhGAP is to build partnerships for collective action and to reinforce the commitment of governments, international organisations and other stakeholders.

The mhGAP Intervention Guide (mhGAP-IG) was launched in October 2010. It is a technical tool for the management of mental, neurological and substance use disorders in non-specialist health settings. The priority conditions included are: depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and other significant emotional or medically unexplained complaints.

Criticism

One of the most prominent critics of the Movement for Global Mental Health has been China Mills, author of the book Decolonising Global Mental Health: The Psychiatrisation of the Majority World. Mills writes that:[7]

This book charts the creeping of psychology and psychiatry across the borders of everyday experience and across geographical borders, as a form of colonialism that comes from within and from outside, swallowed in the form of a pill. It maps an anxious space where socio-economic crises come to be reconfigured as individual crisis – as ‘mental illness’; and how potentially violent interventions come to be seen as ‘essential’ treatment.

Another prominent critic is Ethan Watters, author of Crazy Like Us: The Globalisation of the American Psyche. A more constructive approach is offered by Vincenzo Di Nicola whose article on the Global South as an emergent epistemology creates a bridge between critiques of globalisation and the initial gaps and limitations of the Global Mental Health movement.

A recent review presents a simple summary outlining the key characteristics of the global mental health landscape and indicating the diversity existing within the field. This review demonstrates how the area is not confined to the limits of the local-global debate, which has historically defined it.

What is the Gatsby Charitable Foundation?

Introduction

The Gatsby Charitable Foundation is an endowed grant-making trust, based in London, founded by David Sainsbury in 1967.

Background

The organisation is one of the Sainsbury Family Charitable Trusts, set up to provide funding for charitable causes. Although the organisation is permitted in its Trust Deed to make general grants within this broad area, its activities have generally been restricted to a limited number of fields. At the time of writing, these fields are:

  • Science and Engineering Education.
  • Plant science.
  • Neuroscience.
  • Poverty alleviation in Africa.
  • The arts.
  • Public policy.

However, these categories may change from time to time.

Amongst its activities, the Gatsby Charitable Foundation funds the Gatsby Computational Neuroscience Unit at University College London, the Sainsbury Management Fellowships, the Institute for Government based in Carlton House Terrace, and the Sainsbury Laboratory. It has long funded the Centre for Mental Health but is mostly withdrawing that funding in 2010. More recently, the foundation has become a co-sponsor of the University Technical Colleges programme, in conjunction with the Baker Dearing Trust.

According to the OECD, the Gatsby Charitable Foundation’s financing for 2019 development increased by 40% to US$18.9 million.

An Overview of Mental Health in China

Introduction

Mental health in China is a growing issue. Experts have estimated that about 173 million people living in China are suffering from a mental disorder.

The desire to seek treatment is largely hindered by China’s strict social norms (and subsequent stigmas), as well as religious and cultural beliefs regarding personal reputation and social harmony. While the Chinese government is committed to expanding mental health care services and legislation, the country struggles with a lack of mental health professionals and access to specialists in rural areas.

Brief History

China’s first mental institutions were introduced before 1849 by Western missionaries. Missionary and doctor John G. Kerr opened the first psychiatric hospital in 1898, with the goal of providing care to people with mental health issues, and treating them in a more humane way.

In 1949, the country began developing its mental health resources by building psychiatric hospitals and facilities for training mental health professionals. However, many community programs were discontinued during the Cultural Revolution.

In a meeting jointly held by Chinese ministries and the World Health Organisation (WHO) in 1999, the Chinese government committed to creating a mental health action plan and a national mental health law, among other measures to expand and improve care. The action plan, adopted in 2002, outlined China’s priorities of enacting legislation, educating its people on mental illness and mental health resources, and developing a stable and comprehensive system of care.

In 2000, the Minority Health Disparities Research and Education Act was enacted. This act helped in raising national awareness on health issues through research, health education, and data collection.

Since 2006, the government’s 686 Program has worked to redevelop community mental health programs and make these the primary resource, instead of psychiatric hospitals, for people with mental illnesses. These community programs make it possible for mental health care to reach rural areas, and for people in these areas to become mental health professionals. However, despite the improvement in access to professional treatment, mental health specialists are still relatively inaccessible to rural populations. The program also emphasizes rehabilitation, rather than the management of symptoms.

In 2011, the legal institution of China’s State Council published a draft for a new mental health law, which includes new regulations concerning the rights of patients to not to be hospitalised against their will. The draft law also promotes the transparency of patient treatment management, as many hospitals were driven by financial motives and disregarded patients’ rights. The law, adopted in 2012, stipulates that a qualified psychiatrist must make the determination of mental illness; that patients can choose whether to receive treatment in most cases; and that only those at risk of harming themselves or others are eligible for compulsory inpatient treatment. However, Human Rights Watch has criticised the law. For example, although it creates some rights for detained patients to request a second opinion from another state psychiatrists and then an independent psychiatrist, there is no right to a legal hearing such as a mental health tribunal and no guarantee of legal representation.

Since 1993, WHO has been collaborating with China in the development of a national mental health information system.

Current Situation

Though China continues to develop its mental health services, it still has a large number of untreated and undiagnosed people with mental illnesses. The aforementioned intense stigma associated with mental illness, a lack of mental health professionals and specialists, and culturally-specific expressions of mental illness may play a role in the disparity.

Prevalence of Mental Disorders

Researchers estimate that roughly 173 million people in China have a mental disorder. Over 90 percent of people with a mental disorder have never been treated.

A lack of government data on mental disorders makes it difficult to estimate the prevalence of specific mental disorders, as China has not conducted a national psychiatric survey since 1993.

Conducted between 2001 and 2005, a non-governmental survey of 63,000 Chinese adults found that 16 percent of the population had a mood disorder, including 6% of people with major depressive disorder. Thirteen percent of the population had an anxiety disorder and 9 percent had an alcohol use disorder. Women were more likely to have a mood or anxiety disorder compared to men, but men were significantly more likely to have an alcohol use disorder. People living in rural areas were more likely to have major depressive disorder or alcohol dependence.

In 2007, the Chief of China’s National Centre for Mental Health, Liu Jin, estimated that approximately 50% of outpatient admissions were due to depression.

There is a disproportionate impact on the quality of life for people with bipolar disorder in China and other East Asian countries.

The suicide rate in China was approximately 23 per 100,000 people between 1995 and 1999. Since then, the rate is thought to have fallen to roughly 7 per 100,000 people, according to government data. WHO states that the rate of suicide is thought to be three to four times higher in rural areas than in urban areas. The most common method, poisoning by pesticides, accounts for 62% of incidences.

It is estimated that 18% of the Chinese population, about 244 million people believe in Buddhism. Another 22% of the population, roughly 294 million people believe in folk religions which are a group of beliefs that share characteristics with Confucianism, Buddhism, Taoism, and shamanism. Common between all of these philosophical and religious beliefs is an emphasis on acting harmoniously with nature, with strong morals, and with a duty to family. Followers of these religions perceive behaviour as being tightly connected with health; illnesses are often thought to be a result of moral failure or insufficiently honouring one’s family in current or past life. Furthermore, an emphasis on social harmony may discourage people with mental illness from bringing attention to themselves and seeking help. They may also refuse to speak about their mental illness because of the shame it would bring upon themselves and their family members, who could also be held responsible and experience social isolation.

Also, reputation might be a factor that prevents individuals from seeking professional help. Good reputations are highly valued. In a Chinese household, every individual shares the responsibility of maintaining and raising the family’s reputation. It is believed that mental health will hinder individuals from achieving the standards and goals- whether academic, social, career-based, or other- expected from parents. Without reaching the expectations, individuals are anticipated to bring shame to the family, which will affect the family’s overall reputation. Therefore, mental health issues are seen as an unacceptable weakness. This perception of mental health disorders causes individuals to internalise their mental health problems, possibly worsening them, and making it difficult to seek treatment. Eventually, it becomes ignored and overlooked by families.

In addition, many of these philosophies teach followers to accept one’s fate. Consequently, people with mental disorders may be less inclined to seek medical treatment because they believe they should not actively try to prevent any symptoms that may manifest. They may also be less likely to question the stereotypes associated with people with mental illness, and instead agreeing with others that they deserve to be ostracised.

Lack of Qualified Staff

China has 17,000 certified psychiatrists, which is 10% of that of other developed countries per capita. China averages one psychologist for every 83,000 people, and some of these psychologists are not board-licensed or certified to diagnose illnesses. Individuals without any academic background in mental health can obtain a license to counsel, following several months of training through the National Exam for Psychological Counsellors. Many psychiatrists or psychologists study psychology for personal use and do not intend to pursue a career in counselling. Patients are likely to leave clinics with false diagnoses, and often do not return for follow-up treatments, which is detrimental to the degenerative nature of many psychiatric disorders.

The disparity between psychiatric services available between rural and urban areas partially contributes to this statistic, as rural areas have traditionally relied on barefoot doctors since the 1970s for medical advice. These doctors are one of the few modes of healthcare able to reach isolated parts of rural China, and are unable to obtain modern medical equipment, and therefore, unable to reliably diagnose psychiatric illnesses. Furthermore, the nearest psychiatric clinic may be hundreds of kilometres away, and families may be unable to afford professional psychiatric treatment for the afflicted.

Physical Symptoms

Multiple studies have found that Chinese patients with mental illness report more physical symptoms compared to Western patients, who tend to report more psychological symptoms. For example, Chinese patients with depression are more likely to report feelings of fatigue and muscle aches instead of feelings of depression. However, it is unclear whether this occurs because they feel more comfortable reporting physical symptoms or if depression manifests in a more physical way among Chinese people.

Misuse

According to various scholars, China’s psychiatric facilities have been manipulated by government officials in order to silence political dissidents. In addition to misuse by the state psychiatric facilities in China are also misused by powerful private individuals who use the system to advance their personal or business ends. China’s legal system lacks an effective means of challenging involuntary detentions in psychiatric facilities.

Chinese Military Mental Health

Overview

Military mental health has recently become an area of focus and improvement, particularly in Western countries. For example, in the United States, it is estimated that about twenty-five percent (25%) of active military members suffer from a mental health problem, such as PTSD, Traumatic Brain Injury, and depression. Currently, there are no clear initiatives from the government about mental health treatment towards military personnel in China. Specifically, China has been investing in resources towards researching and understanding how the mental health needs of military members and producing policies to reinforce the research results.

Background

Research on the mental health status of active Chinese military men began in the 1980s where psychologists investigated soldiers’ experiences in the plateaus. The change of emphasis from physical to mental health can be seen in China’s four dominant military academic journals: First Military Journal, Second Military Journal, Third Military Journal, and Fourth Military Journal. In the 1980s, researchers mostly focused on the physical health of soldiers; as the troops’ ability to perform their services declined, the government began looking at their mental health to provide an explanation for this trend. In the 1990s, research on it increased with the hope that by improving the mental health of soldiers, combat effectiveness improves.

Mental health issue can impact active military members’ effectiveness in the army, and can create lasting effects on them after they leave the military. Plateaus were an area of interest in this sense because of harsh environmental conditions and the necessity of the work done with low atmospheric pressure and intense UV radiation. It was critical to place the military there to stabilize the outskirts and protect the Chinese citizens who live nearby; this made it one of the most important jobs in the army, then increasing the pressure on those who worked in the plateaus. It not only affected the body physically, like in the arteries, lungs, and back, but caused high levels of depression in soldiers because of being away from family members and with limited communication methods. Scientists found that this may impact their lives as they saw that this population had higher rates of divorce and unemployment.

Comparatively, assessing the mental health status of the People’s Liberation Army (PLA) is difficult, because military members work a diverse array of duties over a large landscape. Military members also play an active part in disaster relief, peacekeeping in foreign lands, protecting borders, and domestic riot control. In a study of 11,000 soldiers, researchers found that those who work as peacekeepers have higher levels of depression compared to those in the engineering and medical departments. With such diverse military roles over an area of 8.4 million square kilometres (3.25 million square miles), it is difficult to gauge its impacts on soldiers’ psyche and provide a single method to address mental health problems.

Researches have increased over the last two decades, but the studies still lack a sense of comprehensiveness and reliability. In over 73 studies that together included 53,424 military members, some research shows that there is gradual improvement in mental health at high altitudes, such as mountain tops; other researchers found that depressive symptoms can worsen. These research studies demonstrate how difficult it is to assess and treat the mental illness that occurs in the army and how there are inconsistent results. Studies of the military population focus on the men of the military and exclude women, even though the number of women that are joining the military has increased in the last two decades.

Chinese researchers try to provide solutions that are preventative and reactive, such as implementing early mental health training, or mental health assessments to help service members understand their mental health state, and how to combat these feelings themselves. Researchers also suggest to improve the mental health of the military members, programmes should include psychoeducation, psychological training, and attention to physical health to employ timely intervention.

Implementation

In 2006, the People’s Republic Minister for National Defence began mental health vetting at the beginning of the military recruitment process. A Chinese military study consisting of 2500 male military personnel found that some members are more predisposed to mental illness. The study measured levels of anxious behaviours, symptoms of depression, sensitivity to traumatic events, resilience and emotional intelligence of existing personnel to aid the screening of new recruits. Similar research has been conducted into the external factors that impact a person’s mental fortitude, including single-child status, urban or rural environment, and education level. Subsequently, the government has incorporated mental illness coping techniques into their training manual. In 2013 leak by the Tibetan Centre for Human Rights of a small portion of the People’s Liberation Army training manual from 2008, specifically concerned how military personnel could combat PTSD and depression while on peacekeeping missions in Tibet. The manual suggested that soldiers should:

“…close [their] eyes and imagine zooming in on the scene like a camera [when experiencing PTSD]. It may feel uncomfortable. Then zoom all the way out until you cannot see anything. Then tell yourself the flashback is gone.”

In 2012, the government specifically addressed military mental health in a legal document for the first time. In article 84 of the Mental Health Law of the People’s Republic of China, it stated, “The State Council and the Central Military Committee will formulate regulations based on this law to manage mental health work in the military.”

Besides screening, assessments and an excerpt of the manual, not much is known about the services that are provided to active military members and veterans. Analysis of more than 45 different studies, moreover, has deemed that the level of anxiety in current and ex-military personnel has increased despite efforts of the People’s Republic due to economic conditions, lack of social connects and the feeling of a threat to military livelihood. This growing anxiety manifested in both 2016 and 2018, as Chinese veterans demonstrated their satisfaction with the system via protests across China. In both instances, veterans advocated for an increased focus on post-service benefits, resources to aid in post-service jobs, and justice for those who were treated poorly by the government. As a way to combat the dissatisfaction of veterans and alleviate growing tension, the government established the Ministry of Veteran Affairs in 2018. At the same time, Xi Jinping, General Secretary of the Communist Party of China, promised to enact laws that protect the welfare of veterans.

32 Pills: My Sister’s Suicide (2017)

Introduction

She’s beautiful, artistic, loved and can’t stand to be alive. 32 PILLS traces the fascinating life and mental illness of my sister, New York artist and photographer Ruth Litoff, and my struggle to come to terms with her tragic suicide.

Outline

After struggling with mental illness for most of her life, New York artist Ruth Litoff committed suicide at age 42 in 2008 by overdosing on prescription pills. Six years later, her younger sister, Hope Litoff, decides to film herself while she empties a packed-to-the-brim storage unit filled with Ruth’s belongings, driven by the need to understand Ruth’s illness and desire to end her life – but as she pores through the items her sister left behind, she must exorcise the demons that threaten her sobriety.

Read the rest of the HBO synopsis here.

Cast

  • Ruth Litoff as self.
  • Hope Litoff as Self.

Production & Filming Details

  • Director(s):
    • Hope Litoff.
  • Producer(s):
    • Dan Cogan … executive producer.
    • Steven H. Cohen … co-executive producer.
    • Paula M. Froehle … co-executive producer.
    • Lise King … social impact producer.
    • Beth Levison … producer.
    • Sheila Nevins … executive producer.
    • Regina K. Scully … executive producer (as Regina Kulik Scully).
  • Writer(s):
  • Music:
    • Todd Griffin.
  • Cinematography:
    • Daniel B. Gold.
  • Editor(s):
    • Toby Shimin.
  • Production:
    • HBO Documentary Films.
  • Distributor(s):
    • Home Box Office (HBO) (2016) (USA) (TV).
  • Release Date: 01 May 2017 (Canada, Hot Docs International Documentary Festival).
  • Running Time: 89 minutes.
  • Rating: TV-MA.
  • Country: US.
  • Language: English.

P.O.V. Neurotypical (2013)

Introduction

P.O.V. Neurotypical is a 2013 documentary film directed by Adam Larsen.

The film shows perspectives on life from the viewpoint of individuals on the autism spectrum. Neurotypical was shot mostly in North Carolina and Virginia.

Edited from Neurotypical in 2011.

Outline

Neurotypical is an unprecedented exploration of autism from the point of view of autistic people themselves. Four-year-old Violet, teenaged Nicholas and adult Paula occupy different positions on the autism spectrum, but they are all at pivotal moments in their lives. How they and the people around them work out their perceptual and behavioural differences becomes a remarkable reflection of the “neurotypical” world – the world of the non-autistic – revealing inventive adaptations on each side and an emerging critique of both what it means to be normal and what it means to be human.

Cast

  • Wolf Dunaway as himself.
  • Violet as herself.
  • Nicholas as himself.
  • Paula as herself.
  • Maddi as herself.
  • John as himself.

Production & Filming Details

  • Director(s):
    • Adam Larsen.
  • Producer(s):
  • Writer(s):
  • Music:
    • Darren Morze.
    • Michael Wall.
  • Cinematography:
    • Adam Larsen.
  • Editor(s):
    • Adam Larsen.
  • Production:
  • Distributor(s):
    • Janson Media (2013) (USA) (video).
    • Janson Media (2015) (USA) (video).
  • Release Date: 29 July 2013.
  • Running Time: 52 or 57 minutes.
  • Rating: Unknown.
  • Country: US.
  • Language: English.

Neurotypical (2011)

Introduction

Neurotypical is a 2011 documentary film directed by Adam Larsen.

The film shows perspectives on life from the viewpoint of individuals on the autism spectrum. Neurotypical was shot mostly in North Carolina and Virginia.

Edited into P.O.V. Neurotypical in 2013.

Outline

Neurotypical is an unprecedented exploration of autism from the point of view of autistic people themselves. Four-year-old Violet, teenaged Nicholas and adult Paula occupy different positions on the autism spectrum, but they are all at pivotal moments in their lives. How they and the people around them work out their perceptual and behavioural differences becomes a remarkable reflection of the “neurotypical” world – the world of the non-autistic – revealing inventive adaptations on each side and an emerging critique of both what it means to be normal and what it means to be human.

Cast

  • Wolf Dunaway as himself.
  • Violet as herself.
  • Nicholas as himself.
  • Paula as herself.
  • Maddi as herself.
  • John as himself.

Production & Filming Details

  • Director(s):
    • Adam Larsen.
  • Producer(s):
  • Writer(s):
  • Music:
    • Darren Morze.
    • Michael Wall.
  • Cinematography:
    • Adam Larsen.
  • Editor(s):
    • Adam Larsen.
  • Production:
  • Distributor(s):
    • Janson Media (2013) (USA) (video).
    • Janson Media (2015) (USA) (video).
  • Release Date: March 2011 (Thessaloniki Documentary Festival).
  • Running Time: 52 minutes.
  • Rating: Unknown.
  • Country: US.
  • Language: English.

What is the Mental Health Association of San Francisco?

Introduction

The Mental Health Association of San Francisco (MHA-SF) is a charitable organisation which deals with mental health education, advocacy, research, and service in San Francisco.

It was established as the San Francisco Mental Hygiene Society in 1947. The present name was adopted in 1957.

The San Francisco-based organisation is one of 320 affiliates of Mental Health America (formerly known as the National Mental Health Association) throughout the United States and an affiliate of the Mental Health Association in California.

It has received core funding from The California Endowment.

What is the Campaign Against Living Miserably?

Introduction

Campaign Against Living Miserably, or CALM, is a registered charity based in England.

CALM run a free, confidential and anonymous helpline as well as a webchat service, offering help, advice and information to anyone who is struggling or in crisis.

Brief History

Pilot and Relaunch

CALM was initially a Department of Health pilot project launched late in 1997 in Manchester with the help of Tony Wilson, and then rolled out to Merseyside in 2000. It was a helpline targeted specifically at young men who were unlikely to contact mainstream services and who were at greater risk of suicide. Jane Powell was commissioned to launch the project and ran it until 2000. When funding for the pilot project ceased in 2004/2005, Powell relaunched the pilot as a registered charity in 2006 working with some of the pilot’s original commissioners and with Tony Wilson as a founding Trustee.

In 2015 rapper and singer-songwriter Professor Green was named as CALM’s patron, and the campaign’s Trustees Board includes health professionals and leading figures from the worlds of music, advertising, and management, as well as relatives of men who have taken their own lives. Robin Millar and David Baddiel are former patrons.

The campaign has brought in significant pro bono advertising support from agencies such as Ogilvy Advertising, Tullo Marshall Warren, MTV, and Metro, and most recently Topman and BMB. This has brought CALM a significant amount of advertisements on billboards, on TV, in the underground and on radio.

In November 2018, CALM partnered with UKTV channel Dave to create a campaign called “Be The Mate You’d Want”. This started with a 3-minute ad break, voiced by comedian James Acaster, encouraging the viewer to text, chat or tweet someone who needs support. It occurred again in July 2019, this time with a “comedy festival in an ad break” which featured comedians Ahir Shah, Alex Horne, Dane Baptiste, Darren Harriott, David Mumeni, Ed Gamble, Elf Lyons, Jamali Maddix, Jessie Cave, Lou Sanders, Maisie Adam, Natasia Demetriou, Phil Wang, Pierre Novelli, Sindhu Vee, Stevie Martin and Zoe Lyons, with Jessica Knappett providing intro and outro voiceover.

Project84

In 2018, the charity commissioned the artists Mark Jenkins and Sandra Fernandez to create Project84, an art installation in London, England. The work was sponsored by Harry’s and designed to raise awareness of adult male suicide.

Conversations Against Living Miserably

In May 2019 CALM announced a partnership with Dave for a podcast called Conversations Against Living Miserably hosted by Lauren Pattison and Aaron Gillies talking to comedians about their mental health.