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Unmet Need in Psychiatry: Problems, Resources, Responses Edited by Gavin Andrews & Scott Henderson. Cambridge: Cambridge University Press. 2000. 440 pp. $55.00 (hb). ISBN 0 521 66229 X

Published online by Cambridge University Press:  02 January 2018

Frank Holloway*
Affiliation:
South London and Maudsley NHS Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK
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Abstract

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Columns
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Copyright © 2002 The Royal College of Psychiatrists 

This valuable book arose from a conference held in Sydney in 1997 under the auspices of the World Psychiatric Association's Section of Epidemiology and Public Health. Its underlying theme is the applicability of the findings of psychiatric epidemiology in shaping a policy response to meeting the needs of people with a ‘mental disorder’ (those disorders listed in DSM-IV and Chapter V of ICD-10). The scale of the problem is enormous. The World Bank Global Burden of Disease project has reported that mental disorders account for about 10% of the burden of disease world-wide — and over 20% in the otherwise much healthier West. Compare this with the negligible spending on mental health by developing nations and the 5-10% of health budgets typically devoted to mental health services in advanced industrial countries. A series of careful epidemiological studies using refined methodologies carried out over the past 20 years in the USA, Canada, UK and, most recently, Australia have identified a 1-year-period prevalence of mental disorder in between 20% and 30% of the adult population. (The UK is scolded for adopting a non-standard methodology in its national psychiatric morbidity survey but its findings are broadly similar.) Anxiety, depression, substance misuse and personality disorder are overwhelmingly more prevalent than psychosis (which tends to be underreported in community surveys). Roughly a quarter of cases will be continually ill throughout the year, with onset cases and remitted cases balancing out.

The epidemiology maps poorly onto real life, with only a small proportion of identified cases receiving treatment and a significant proportion of those receiving treatment failing to meet diagnostic criteria for mental disorder. Treatment resources are overwhelmingly devoted to in-patient care, which in turn is predominantly for people with psychosis (and in some countries substance misuse). Part of the gap between epidemiology and real life is explained by a discordance between diagnosis and disability: many people who meet diagnostic criteria for mental disorder function well (and not a few who do not meet the criteria function badly). Symptoms do not equate to need. Just as important in explaining the gap between epidemiology and service use are the choices of the individual to label their experience a mental disorder and to seek help. Many health care systems actively discourage help-seeking in an effort to contain costs or (what is in effect the same thing) deal with overwhelming demand. There is a further discordance, rather shocking for those who espouse evidence-based medicine, between the public and professionals about what constitutes an appropriate response to a perceived mental disorder. For example, medication comes low down the public list as an effective treatment for schizophrenia. In contrast, there is enormous enthusiasm, in both developed and developing countries, for ‘alternative’ therapies, which are rarely provided by mainstream mental health services. This reflects a chasm between the conceptual frameworks currently adopted by professionals and the public, a chasm that cannot be bridged by recourse to epidemiology alone.

So, what to do? This book vindicates the broad UK strategy for mental health, which combines an emphasis on health promotion with an acknowledgement of the crucial role of primary care in the management of common mental disorders and a requirement of secondary services to deploy evidence-based treatments that can deliver demonstrable health gain. A fuller dialogue between researchers, practitioners, service users and carers might help untangle some of the knots revealed in this book.

References

EDITED BY SIDNEY CROWN and ALAN LEE

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