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Book Forum: International Views   |    
Fighting for Mental Health: A Personal View
LAURA L. POST, M.D., Ph.D.
Am J Psychiatry 2003;160:1712-a-1713. doi:10.1176/appi.ajp.160.9.1712-a
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Saipan, MP (USA)

By Norman Sartorius. New York, Cambridge University Press, 2002, 256 pp., $45.00.

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The global medical era may be characterized by the reality of failed administrative reforms, by the oppression of snowballing disease catastrophes, by the tragedy of 500 million untreated and unacknowledged mentally ill children and adults, and by the uneasy context of new wars in the Mideast. The notion of fighting for mental health intrigued me as a psychiatrist practicing in a remote, underserved, and very diverse area of the United States; many of my patients are seeking something worthwhile in which to believe. The author’s attempt to critically address broad problems within the world’s mental health care system is courageous, particularly since there is an implied offer of solutions. This book delivers on its promise, and more. It is refreshingly delightful in its demonstrations of good sense, gracious manners, and admitted subjectivity while proposing some timely and vital avenues for further consideration.

Formerly President of the World Psychiatric Association and still active with the World Health Organization (WHO), among many other groups, Dr. Sartorius brings credible perspective and experience to his task. A simple three-section design draws the reader into a collection of humanistic-scientific essays, each of which is introduced by a telling artistic image and all of which are punctuated by fascinating points of history. (Did you know that the term "Third World" once referred to those countries which were not the United States or the U.S.S.R.—First World—and also not imperialist?)

Part 1 begins with civic principles. Although these include equity, solidarity, and recognition of the duties and rights of members, Dr. Sartorius opines that the establishment and maintenance of internationally viable mental health programs require more than 1) kind intentions, 2) a pilot survey or two, 3) a vague ideology of "mad" versus "bad," 4) the importation of a few traditionally trained experts and/or the traditional training of a few local leaders, 5) misplaced emphasis on rural settings (by 2020, 80% of the planet’s population will live in cities), and 6) a modest one-time fiscal investment. Dr. Sartorius goes on to note that 1) increasingly sophisticated methodologies inhibit widespread research and 2) study-based conclusions take decades to be translated into meaningful social change, partly because the knowledge that the mental health sciences have produced is still not translated into data that are comprehensible to political authorities and partly because the interventions that are generated are not made ready for nonspecialists to apply.

In part 2, Dr. Sartorius observes that psychiatry and medicine are historically separated by the physical distance between sites of practice, by divergences of diagnostic and treatment techniques, and by disparate relations to legal procedures. He points out that the intercalation of specialized mental health nosology and remedies with primary, or "essential," health care—as defined by WHO at the 1978 meeting in Alma Ata, then capital of Kazakhstan—is inhibited both by the reluctance of mental health practitioners to entrust their patients to the intense and unempathic settings of primary care and by the inability of primary care practitioners to perceive some psychiatric conditions as requiring essential services and materials, despite the consensus that some psychiatric disorders are frequent, have grave consequences, and exert an impact on general socioeconomic development (such as in the elderly).

Part 3 focuses on the concepts of authentic needs assessment and prevention of neurological disorders with a view toward multidisciplinary teams, psychosocial rehabilitation, and cultural strategizing for "foreign" patient populations. The conclusions of Dr. Sartorius agree to a very high degree with mine in my Ph.D. dissertation about how to establish and maintain productive mental health and substance abuse systems in small, isolated communities such as the Commonwealth of the Northern Mariana Islands (U.S.A.).

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