World Council of Churches

A worldwide fellowship of churches seeking unity, a common witness and Christian service

Mental health

01 April 2004

by Prathap Tharyan, Deepa Braganza, Prasanna Jebaraj 

ABSTRACT: Mental and behavioural disorders are common, and affect more than 25% of all people at some time during their lives. Mental disorders are also universal, and affect people of all countries and societies, individuals at all ages, women and men, and the rich and the poor from urban and rural environments. One in four families is likely to have at least one member with a behavioural or mental disorder. Suicide is a leading cause of death in many regions of the world and there is also a rising trend for suicides in these regions. It is estimated that mental disorders contribute a large share to the Global Disease Burden, and account for 33% of the years lived with disability worldwide. This burden caused by neuropsychiatric disorders is expected to increase over the years and will soon surpass the burden posed by HIV/AIDS. The resources available in the form of trained mental health professionals and psychiatric services are, and will continue to be, woefully inadequate to meet the needs posed by the increasing burden. The World Health Organization in its Mental Health Global Action Programme (WHO mhGAP) has outlined the needs of those with mental health problems and the actions that are required to meet these needs. This paper provides an elaboration of a presentation at an international consultation, and the ensuing recommendations of ways in which churches could play a significant role in partnering the WHO mhGAP in bridging the ever-widening gap between resources and needs in mental health. Could mental health be the new frontier that revitalizes the commitment of the church and its congregations to the healing ministry?

Introduction 

The World Health Organization (WHO) declared 2001 as the Year of Mental Health, and it was a watershed year for mental health because it saw the publication by the WHO of The World Health Report 2001. Mental Health: New Understanding; New Hope.i This report presented to the world information concerning the current understanding of mental and behavioural disorders, their magnitude and burden, effective treatment strategies, and strategies for enhancing mental health through policy and service development. The WHO had recognized the importance of mental health from its origin, and this is reflected in the definition of health in the WHO constitution as "not merely the absence of disease or infirmity", but rather, "a state of complete physical, mental and social wellbeing".ii As an extension of this definition, the report made it clear that governments are as responsible for the mental health as for the physical health of their citizens, and, as responsible stewards of any health system, governments must take the responsibility for ensuring that mental health policies are developed and implemented. The report also recommended strategies that countries should pursue, including the integration of mental health treatment and services into the general health system, particularly into primary health care. While this approach is being successfully implemented in many countries, the report said that in others much more remains to be accomplished. 

In this paper, we shall synthesize the information provided in the report and other sources that establish the need to invest in mental health. We hope to capture the sense of urgency required in establishing the programmes and global partnerships that are needed to prevent the inexorable increase in the burden caused by mental health problems. We finally present the recommendations of a consultative meeting at Breklum, Germany,iii that suggests ways in which churches and congregations could partner worldwide programmes and initiatives in the area of mental health. 

Diagnosing mental disorders 

Mental and behavioural disorders are understood as clinically significant conditions characterized by alterations in thinking, mood or behaviour, and associated with personal distress and/or impaired functioning. Mental and behavioural disorders are not just variations within the range of "normal" but are clearly abnormal or pathological phenomena. In order to be categorized as disorders, such abnormalities must be sustained or recurring, and they must result in some personal distress or impaired functioning in one or more areas of life. Mental and behavioural disorders are also characterized by specific symptoms and signs, and usually follow a more or less predictable natural course, unless interventions are made. Not all human distress is mental disorder; unless all the essential criteria for a particular disorder are satisfied, such distress is not a mental disorder. Similarly, culturally determined normal variations in thinking and behaving are not mental disorders. 

Mental and behavioural disorders are identified and diagnosed using clinical methods that are similar to those used for physical disorders. Advances have been made during recent decades in standardizing clinical assessment and improving the reliability of diagnosis, which is a prerequisite for accurate epidemiology and monitoring at the community level, and appropriate intervention at the individual level, as well as to the application of clinical and public health principles to the field of mental health. Structured interview schedules, in which the symptoms and signs have been defined in detail to allow for uniform application, and diagnostic symptom/sign checklists allow mental health professionals to collect information using standard questions and pre-coded responses.iv Diagnostic criteria for disorders have also been standardized internationally.v These advances have now made it possible to achieve a high degree of reliability and validity in the diagnosis of mental disorders; mental disorders can now be diagnosed as reliably and accurately as most of the common physical disorders, such as diabetes mellitus, hypertension or coronary artery disease.vi

Prevalence of mental and behavioural disorders 

Surveys conducted in developed as well as developing countries have shown that during their lifetime more than 25% of individuals develop one or more mental or behavioural disorders.vii In 2004, about 450 million people were estimated to be suffering from neuropsychiatric conditions.viii These conditions included unipolar depressive disorders, bipolar affective disorder, schizophrenia, epilepsy, alcohol and selected drug use disorders, Alzheimer's and other dementias, post-traumatic stress disorder, obsessive and compulsive disorder, panic disorder, and primary insomnia. The most common diagnoses in primary care settings are depression, anxiety and substance abuse disorders. These disorders are present either alone or in addition to one or more physical disorders. 

While in some surveys rates for mental disorders are less in Asian countries than in the rest of the world,ix there are no consistent differences in prevalence between developed and developing countries.x These surveys demonstrate the undeniable fact that mental disorders are not the exclusive preserve of any special group; they are universal, and present in women and men at all stages of the life course. They are present among the rich and poor, and among people living in urban and rural areas. While no group is immune to mental disorders, the risk is higher among the poor, homeless, unemployed, persons with low education, victims of violence, immigrants and refugees, indigenous populations, children and adolescents, abused women and the neglected elderly.xi

The impact of mental and behavioural disorders 

It is difficult to quantify the impact of mental disorders in emotional terms but the suffering caused by mental disorders is undeniable, and affects individuals, families and entire communities. Individuals suffer the distressing symptoms of disorders. They also suffer because they are unable to participate in work and leisure activities, often as a result of discrimination, and they worry about being a burden for others. The burden on families ranges from economic difficulties to emotional reactions to the illness, the stress of coping with disturbed behaviour, the disruption of household routine and the restriction of social activities.xii It is estimated that one in four families has at least one member currently suffering from a mental or behavioural disorder.xiii These families are required not only to provide physical and emotional support but also to bear the negative impact of stigma and discrimination present all over the world. An indirect burden on families in the form of compromises that prevent other members of the family from achieving their full potential in work, social relationships and leisure, lost productivity and opportunities, and constant fears of recurrence of illness are additional, and unquantifiable, ways in which mental disorders impact on families. For communities, there is the cost of providing care, the loss of productivity, and some legal problems, including the potential for violence associated with some mental disorders.xiv

Global burden of disease 

The health burden of any disease for communities and nations has traditionally been measured only in terms of incidence/prevalence and mortality. The use of these indices for chronic and disabling diseases poses serious limitations, particularly for mental and behavioural disorders, which more often cause disability than premature death. 

In 1993, the Harvard School of Public Health, in collaboration with the World Bank and WHO, assessed the global burden of disease.xv They introduced a new measure of disease burden, called "disability - adjusted life year" (DALY), to quantify the burden of disease.xvi The DALY is a health gap measure, which combines information on the impact of premature death and of disability. One DALY can be thought of as one lost year of ‘healthy' life; DALYs for a disease are the sum of the years of life lost due to premature mortality (YLL) in the population, and the years lost due to disability (YLD) for incident cases of the health condition. The DALY is a health gap measure that extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of ‘healthy' life lost in states of less than full health, broadly termed disability.xvii

In 2000, neuropsychiatric disorders accounted for 13% of DALYs worldwide; three neuropsychiatric conditions (unipolar depressive disorders, self-inflicted injuries and alcohol use disorders) ranked in the top twenty leading causes of DALYs for all ages, and six (unipolar depressive disorders, self-inflicted injuries, alcohol use disorders, schizophrenia, bipolar affective disorders and panic disorder) in the age group 15-44.xviii Eight neuropsychiatric conditions ranked among the top 20 leading causes of years lived with disability (YLD) for those aged 15 to 44, and for all ages neuropsychiatric disorders accounted for 33% of all YLDs.xix

It is readily apparent from the above that neuropsychiatric disorders pose a significant burden on world communities, and the burden is growing. More than 150 million people suffer from depression, about 28 million suffer from schizophrenia and more than 90 million suffer from alcohol or drug use disorders at any one time worldwide, and more than one million people commit suicide every year.xx Suicide is a leading cause of death for young adults. It is among the top three causes of death in the population aged 15 to 34. Suicide is predominant in the 15 to 34-year-old age group, where it ranks as the first or second cause of death for both the sexes. This represents a massive loss to societies of young persons in their productive years of life.xxi

 

Mental disorders and physical health 

Mental disorders and physical disorders are interlinked; mental and behavioural disorders are risk factors for physical ill health. For example, depression increases the risk of cancer and heart disease, and people with physical disorders who suffer from depression, anxiety and substance use disorders are often poorly compliant with treatment requirements. Furthermore, a number of behavioural problems, such as smoking and sexual activities, have been linked to the development of physical disorders such as cancer and HIV/AIDS.xxii Treating co-morbid psychiatric disorders could improve the health outcomes of physical disorders. 

Economic costs 

Mental and behavioural disorders also have an economic impact on nations; these disorders result in decreased productivity at work in the form of absenteeism, sick leave and decreased productivity. In many countries, 35% -45% of absenteeism from work is due to mental health problems.xxiii For people with mental disorders, their access to the job market and job retention is affected. The annual expenditure for health services due to mental disorders is also considerable. In a survey done by the United Kingdom's National Heath Service in 1992-1993, mental disorders accounted for around GB£2100 million in treatment and social service costs; this was far more than the combined costs incurred for managing diabetes, breast cancer, ischaemic heart disease and hypertension.xxiv

Quality of life 

While suffering is not readily quantifiable, an indirect method of assessing the impact of mental disorders is to assess the quality of life (QOL) in those with mental and behavioural problems. A number of studies have reported on the quality of life of individuals with mental disorders, and concluded that the negative impact is not only substantial but also sustained.xxv In these studies, quality of life continued to be poor even after recovery from mental disorders, as a result of social factors that included continued stigma and discrimination. Results from QOL studies also suggest that individuals with severe mental disorders, and who live in long-term mental hospitals have a poorer quality of life than those living in the community, and that unmet basic social and functioning needs were the largest predictors of poor quality of life among individuals with severe mental disorders. 

The observations documented herein point to a massive burden to the world caused by mental disorders that affect people in all walks of life, and impact all aspects by which we define our lives, individually and collectively. The indications are that this burden is inexorably increasing and, unless concrete and wide-ranging activities are implemented as matter of utmost priority, the global health agenda in the future will be determined largely by our deficiencies in meeting the needs of those with mental disorders, and facing the consequences of our failure to act now. 

Causes of mental disorders 

In recent years, new information from the fields of neuroscience, in particular neuro-imaging, neurochemistry, genetics, molecular biology and behavioural medicine, has dramatically advanced our understanding of mental functioning. Increasingly, it is becoming clear that mental functioning has a biological basis and that many mental disorders, such as depression, bipolar affective disorders, schizophrenia, panic disorder, obsessive compulsive disorder and even some aspects of alcohol and drug use disorders, have origins steeped in disordered brain function. However, these biological underpinnings are fundamentally interconnected with physical and social functioning and health outcomes. 

Over the past 20 years, mounting scientific evidence from the field of behavioural medicine has demonstrated a fundamental connection between mental and physical health. Studies reveal that women with advanced breast cancer, and who participate in supportive group therapy live significantly longer than women who do not participate in group therapy. Studies also show that depression predicts the incidence of heart disease, and that realistic acceptance of one's own death is associated with decreased survival time in AIDS, even after controlling for a range of other potential predictors of mortality.xxvi Research has demonstrated that the pathways by which mental and physical health mutually influence each other over time are directly through physiological systems, such as neuroendocrine and immune functioning, and indirectly through health behaviour, which is a term that covers a range of activities, such as eating sensibly, getting regular exercise and adequate sleep, avoiding smoking, engaging in safe sexual practices, wearing safety belts in vehicles, and adhering to medical therapies. 

A variety of factors other than biological determine the prevalence, onset and course of mental and behavioural disorders. These include social and economic factors, demographic factors such as sex and age, serious threats such as conflicts and disasters, and the presence of major physical diseases, and the family environment. Poverty and associated conditions of unemployment, low educational level, deprivation and homelessness are not only widespread in poor countries but also affect a sizeable minority of rich countries. Data from cross-national surveys in Brazil, Chile, India and Zimbabwe show that common mental disorders are about twice as frequent among the poor as among the rich.xxvii The course of disorders is also determined by the socio-economic status of the individual.xxviii This may be a result of service-related variables, including barriers to accessing care. Even in rich countries, poverty and associated factors, such as lack of insurance coverage, lower levels of education, unemployment and racial, ethnic and language minority status, create insurmountable barriers to care. Poor countries have few resources for mental health care and these resources are often unavailable to the poorer segments of society. The treatment gap for most mental disorders is large but for the poor population it is massive. 

The overall prevalence of mental and behavioural disorders does not seem to be different between men and women. However, studies show a higher prevalence of depressive and anxiety disorders among women, the usual ratio being between 1.5:1 and 2:1. These findings have been seen not only in developed but also in a number of developing countries.xxix The sex differences in rates of depression are strongly age-related; the greatest differences occur in adult life, with no reported differences in childhood, and few in the elderly. The reasons for higher prevalence of depression and anxiety among women are multiple and include higher stress due to the multiple roles women have to assume, gender biases, the pressures of the reproductive period, and a greater incidence of sexual and domestic violence.xxx Women exposed to domestic violence also report higher rates of suicidal ideation than those not so exposed. Women also bear the brunt of care for the mentally ill within the family. This is becoming increasingly crucial, as more and more individuals with chronic mental disorders are being looked after in the community. 

Age is an important determinant of mental disorders. Besides Alzheimer's disease and other dementias, elderly people also suffer from a number of other mental and behavioural disorders. Overall, the prevalence of some disorders tends to rise with age. Predominant among these is depression. Depressive disorder is common among elderly people: studies show that 8%-20% being cared for in the community, and 37% being cared for at the primary level are suffering from depression.xxxi Depression is more common among older people with physically disabling disorders. The presence of depression further increases the disability among this population. Depressive disorders among elderly people go undetected even more often than among younger adults because these disorders are often mistakenly considered a part of the ageing process. 

Caring for those with mental and behavioural disorders 

Many paradigm shifts in caring for those with mental disorders that occurred over the latter half of the last century revolutionized the way health services approached the care of those with mental disorders. Psychopharmacology made significant progress with the discovery of new classes of drugs, particularly neuroleptics and antidepressants that are as, or more effective and safer than older treatments, as well as the development of new forms of psychosocial interventions. Among these are behaviour therapy, cognitive therapy, interpersonal therapy, relaxation techniques and supportive therapy (counselling) techniques. There was also a greater emphasis on the social and mental components of mental health and recognition of the human rights of persons with mental disorders. These technical and socio-political events contributed to a change in emphasis: from care in large custodial institutions, which over time had become repressive and regressive, to more open and flexible care in the community. Care in the community, as an approach, refers to a number of elements: services, including general hospital care for acute admissions and long-term residential facilities in the community, which are close to home; interventions related to disabilities as well as symptoms; treatment and care specific to the diagnosis and needs of each individual; a wide range of services which address the needs of people with mental and behavioural disorders; services which are co-ordinated between mental health professionals and community agencies; ambulatory rather than static services, including those which can offer home treatment; partnership with carers and meeting their needs; legislation to support the above aspects of care. 

The move to community care has permeated to many parts of the world but in poorer countries the burden of community care often falls on families as government services are unable to provide all components of care envisaged under this approach. Where organized mental health services have been initiated in developing countries in recent times, such services are usually part of primary health care. At one level, this can be seen as a necessity in the face of the lack of trained professionals and resources to provide specialized services. At another level, it is a reflection of the opportunity to organize mental health services in a manner that avoids isolation, stigma and discrimination. The approach of utilizing all the available community resources has the attraction of empowering individuals, families and communities to make mental health an agenda of people rather than of professionals. 

The emergence of consumer movements in a number of countries has changed the way stakeholders' views are seen. These consumer groups are generally composed of people with mental disorders, and their families. In many countries, consumer movements have grown in parallel with traditional mental health advocacy, such as that of family movements. The consumer movement is based on a belief in individual patient choice regarding treatment and other decisions. Probably the best example of a consumer movement is Alcoholics Anonymous, which has become popular around the world and has achieved recovery rates comparable to those obtained by formal psychiatric care. The World Fellowship for Schizophrenia and Allied Disorders (WSF) is a partnership that aims to empower families by developing assertiveness in family carers so that they are able to resolve the many complicated challenges with which they are confronted, rather than having to rely always on professional support.xxxii

As mentioned earlier, another important principle that plays a crucial role in the organization of mental health care is integration into primary health care. Mental disorders are common, and most patients are only seen in primary care but their disorders are often not detected. Also, psychological morbidity is a common feature of physical disease, and emotional distress is often seen but not always recognized by the primary health care professionals. Training primary care and general health care staff in the detection and treatment of common mental and behavioural disorders is an important public health measure. This training can be facilitated by liaison with local community based mental health staff. Experience from African, Asian and Latin American countries shows that adequate training of primary health care workers in the early recognition and management of mental disorders can reduce institutionalization and improve clients' mental health.xxxiii

The needs of people with mental disorders were aptly summarized in the World Health Report 2001 into medical, community, family and rehabilitative efforts.xxxiv

Medical needs include early recognition, and the provision of information about the illness, treatment, appropriate medical care and psychological support, as well as brief hospitalization for more severe cases and when the risk of suicide or violence are detected. Community needs include avoidance of stigma and discrimination through awareness programmes, full social participation in all aspects of life, and recognition of the patient's human rights. Family needs include skills for care, maintaining family cohesion, networking with other families, crisis support, financial support, and respite care when the demands of care become onerous. Rehabilitative needs include social support, housing, access to education, vocational support, day care, long-term care for a minority who have inadequate supports or special needs, and spiritual needs. 

Mental health policy and service provision 

If mental health care is to improve, governments, as the ultimate stewards of mental health, need to assume the responsibility for ensuring that the complex activities involved in establishing effective programmes are carried out. These complex activities include priorities to be set for mental health needs and conditions, among services, treatments, and prevention and promotion strategies, and choices to be made about their funding. Mental health services and strategies must be well co-ordinated among themselves and with other services, such as social security, education, employment and housing. Mental health outcomes must be monitored and analyzed so that decisions can be continually adjusted to meet existing challenges. 

The WHO Project Atlas of Mental Health Resourcesxxxv was established to examine the current status of mental health systems in countries around the world. It involves 181 of WHO's member states, thus covering 98.7% of the world's population. The information was obtained during the period October 2000 to March 2001 from ministries of health, by using a short questionnaire, and was partially validated on the basis of reports from experts and from the published literature. According to these data, one-third of countries do not report a specific mental health budget, although they presumably devote some resources to mental health. Half the rest allocate less than 1% of their public health budget to mental health, even though neuropsychiatric problems represent 12% of the total global burden of disease. A non-existent or limited budget for mental health is a significant barrier to providing treatment and care. Related to this budgetary problem is the fact that approximately four out of ten countries have no explicit mental health policy, and approximately one-third have no drug and alcohol policy. 

Although psychiatric institutions with a large number of beds are not recommended for mental health care, a certain number of beds in general hospitals for acute care is essential. There is a wide variation in the number of beds available for mental health care. The median number for the world population is 1.5 per 10,000 population, ranging from 0.33 in the WHO south-east Asia region, to 9.3 in the European region. Nearly two-thirds of the global population has access to fewer than one bed per 10,000 population, and more than half of all the beds are still in psychiatric institutions, which often provide custodial care rather than mental health care.xxxvi

In developing countries, the lack of specialists and health workers with the knowledge and skills to manage mental and behavioural disorders is an important barrier to providing treatment and care. There is a wide disparity in the type and numbers of the mental health workforce throughout the world. The median number of psychiatrists varies from 0.06 per 100,000 population in low income countries, to 9 per 100,000 in high income countries. For psychiatric nurses, the median ranges from 0.1 per 100,000 in low income countries to 33.5 per 100,000 in high income countries. In almost half the world, there is less than one neurologist per million people.xxxvii

The way forward and the role of churches and congregations 

In the face of the enormous burden posed by mental disorders and the ever widening gap between the need and service provision, the WHO launched the Mental Health Global Action Programme (mhGAP).xxxviii This is an effort to implement the recommendations of the World Health Report. This five-year programme prioritizes services for the most vulnerable population groups, and focuses on prevention, treatment and rehabilitation for people with six priority conditions: depression; schizophrenia; alcohol and drug dependence; dementia; epilepsy; risk of suicide. This programme also aims to increase the responsiveness of governments to mental health concerns, to enhance services, to reduce the burden of mental disorders, and to reduce the devastating impact of stigma and discrimination. 

For such initiatives to succeed, partnerships are required that would complement governmental approaches, especially in 'resource poor' settings. Should the church get involved in this worldwide partnership? An historical precedent to be involved in health-related activities exists in the work of the Christian Medical Commission and the WHO's primary care approach.xxxix A moral imperative may stem from the position that emerged from the famous consultation on the healing ministry organized by the WCC in Tübingen, Germany, in 1964. I that suggests that it is, "only when the Christian community serves the sick person in its midst that it itself becomes healed and whole".xl One of the best examples of how Christian communities can become carers of the mentally ill is to be found in the Belgian town of Geel, which is the site of what is undoubtedly the oldest community mental health programme in the Western world.xli Since the 13th century, and originating perhaps as early as the 8th century, severely mentally ill people have been welcomed by the Church of St Dympha or by foster families in the town, with whom they have lived, often for several decades. Today, such families in Geel care for some 550 patients, about half of whom have jobs in sheltered workshops. Many such initiatives undoubtedly go unreported. 

The World Council of Churches (WCC) mission study and health desks, with the Northelbian Centre for Mission and World Service (NMZ), organized an international and ecumenical study consultation on "The Global Health Situation and the Mission of the Church in the 21st Century" at the Christian-Jensen Kolleg, Breklum, Germany, from 25 September to 30 September, 2005. The consultation identified mental health as a key issue for the churches' role in the mission of the church in the 21st century. The consultation documents mention key areas where it was felt that churches and congregations could get involved in partnering the WHO mhGAP. They are a call to action, and the views, experiences and reflections of those who read them would greatly enrich the process of consultation and collaboration between congregations, churches and the WCC. We acknowledge that churches and congregations would not feel it appropriate or possible to engage in all the activities detailed in the Breklum group reports but these are only representative of the many options that are available for churches to partner international efforts in reducing the burden of mental illness.xlii

Conclusions 

Mental and behavioural disorders are key determinants in the future of global health developments. While there is increasing recognition of the burden posed by these disorders, the resources available to meet current and future needs would require a global collaboration between governments and non-governmental agencies. Churches and congregations are not exempt from the effects of these disorders, and this paper suggests ways in which churches could play a significant role in partnering the international effort in bridging the ever widening gap between resources and needs in mental health. Mental health could be the new frontier that revitalizes the commitment of the church and its congregations to the healing ministry, just as the Christian Medical Commission revitalized the World Health Organization and the face of global health care forever.

The authors:

Professor Prathap Tharyan is head of the Department of Psychiatry at the Christian Medical College (CMC) in Vellore, India. He is an editor with the Cochrane Schizophrenia Group that is part of the Cochrane Collaboration, an international not-for-profit organization that prepares, maintains and disseminates systematic reviews of the effectiveness of interventions used in health care

Deepa Braganza is an associate professor of psychiatry at CMC Vellore and is a clinician, teacher and researcher with a special interest in alleviating and managing pain

Prasanna Jebraj is a reader in psychiatry at the same institution. She is also a clinician, teacher and researcher with a special interest in spiritual aspects of health care, and reaching the marginalized and underprivileged

NOTES 

iThe World Health Report 2001. Mental Health: New Understanding, New Hope, World Health Organization, Geneva, 2001. This report is available for free download as pdf documents from the WHO website: http://www.who.int/whr/2001/en/

iiWorld Health Organization, Constitution of the World Health Organization, available at http://policy.who.int/cgi-bin/om_isapi.dll?hitsperheading=on&infobase=basicdoc&jump=Constitution&softpage= Document42#JUMPDEST_Constitution. The constitution was adopted by the International Health Conference held in New York from 19 June to 22 July 1946, signed on 22 July 1946 by the representatives of 61 States (Off. Rec. Wld Hlth Org., 2, p. 100), and entered into force on 7 April 1948.

iiiThe World Council of Churches (WCC) mission study and health desks, with the Northelbian Centre for World Mission and World Service (NMZ), organized an international and ecumenical study consultation on "The Global Health Situation and the Mission of the Church in the 21st Century" at the Christian-Jensen Kolleg, Breklum, Germany, from 25 September to 30 September, 2005. Mental Health was identified as a key issue for the churches' role in the mission of the church in the 21st century.

ivL.N. Robins, John Wing, H-U Wittchen, J.E. Heltzer, T.F. Babor, J. Burke, A. Farmer, Aslen Jablenski, R. Pickens, D.A. Regier, et al., "The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures", Archives of General Psychiatry, No. 45, 1988, pp. 1069-1077. This instrument (CIDI) was expanded to include detailed questions about severity, impairment and treatment, and has been used extensively in the WHO world mental health surveys in 28 countries, including less developed regions.

vThe ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines, World Health Organization, Geneva, 1992.

viThe World Health Report 2001, op. cit., p 22. The concordance, or degree of agreement, between two experts in the diagnosis of mental disorders averages 0.7 to 0.9. A concordance of 1 denotes perfect agreement.

viiThe WHO World Mental Health Survey Consortium, "Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys", Journal of the American Medical Association, No. 291, 2004, pp 2581-2590.

viiiThe WHO World Mental Health Survey Consortium, op. cit., p. 2585.

ixDavid Goldberg and Y. Lecrubier, "Form and frequency of mental disorders across centres", in Mental illness in general health care: an international study, T.B. Üstün and Norman Sartorius, eds, Chichester, John Wiley & Sons on behalf of WHO, 1995, pp. 323-334.

xThe World Health Report 2001, op. cit., p. 23.

xiInvesting in Mental Health, World Health Organization, Geneva, 2003, p. 7.

xiiAn overview of a strategy to improve the mental health of underserved populations: Nations for Mental Health, World Health Organization, Geneva, 1997, unpublished document WHO/MSA/NAM/97.3.

xiiiThe World Mental Health Report 2001, op. cit., p. 24. This implies that one in four people reading this paper has a family member with a mental or behavioural disorder, or has personally suffered from such a disorder.

xivWhile some persons with mental disorders exhibit violence, it is often people without mental disorders who cause violence much more than individuals with mental disorders.

xvWorld Bank, World development report 1993: investing in health, Oxford University Press for the World Bank, New York, 1993.

xviChristopher J.L. Murray and A.D. Lopez, "Progress and directions in refining the global burden of disease approach: a response to Williams", Health Economics, No. 9, 2000, pp. 69-82.

xviiThe World Health Report 2001, op. cit., p. 25.

xviiiIbid., p. 27.

xixIbid., p. 28.

xxInvesting in Mental Health, op. cit., p. 8.

xxiThe World Health Report 2001, op. cit., p. 38.

xxiiInvesting in Mental Health, op. cit., pp. 9-10.

xxiiiIbid., p. 19.

xxivNHS Executive, Department of Health (United Kingdom), Burdens of Disease; a discussion document, Department of Health, London, 1996; figures for economic burden taken from WHO, Investing in Mental Health, op. cit., p. 17.

xxvUK700 Group, "Predictors of quality of life in people with severe mental illness", British Journal of Psychiatry, No. 175, 1999, pp. 426-432.

xxviThe World Health Report 2001, op. cit., p 8.

xxviiVikram Patel, "Poverty, inequality, and mental health in developing countries", in D. Leon and G. Walt, eds, Poverty, inequality and health: an international perspective, Oxford University Press, Oxford, 2001, pp. 247-261.

xxviiiBenedetto Saraceno and C. Barbui, "Poverty and mental illness", Canadian Journal of Psychiatry, No. 42, 1997, pp. 285-290.

xxixVikram Patel, Ricardo Araya, Mauricio de Lima, A. Ludermir, C. Todd, "Women, poverty and common mental disorders in four restructuring societies", Social Science and Medicine, No. 49, 1999, pp. 1461-1471.

xxxWomen's mental health: an evidence-based review, World Health Organization, Geneva, 2000 (unpublished document WHO/MSD/MHP/00.1), cited in WHO, The World Health Report 2001, op. cit., p. 127.

xxxiThe World Health Report 2001, op. cit., p. 43.

xxxiiInformation about the World Fellowship for Schizophrenia and Allied Disorders (WFSAD) can be accessed via their Website: http://www.world-schizophrenia.org/.

xxxiiiThe World Health Report 2001, op. cit., p. 59.

xxxivIbid., p. 60.

xxxvMental health resources in the world. Initial results of Project Atlas, World Health Organization, Geneva, 2001, p. 260.

xxxviThe World Health Report 2001, op. cit., pp. 85-86.

xxxviiIbid., pp. 95-97.

xxxviiiInformation on the World Health Organization, mental health Global Action Programme (mhGAP), can be accessed via, http://www.who.int/mental_health/actionprogramme/en/index.html.

xxxixSocrates Litzios, "The Christian Medical Commission and the development of the World Health Organization's primary care approach", American Journal of Public Health, No. 94, 2004, pp. 1884-1893. This paper details the role of the WCC and its Christian Medical Commission that helped the WHO institute its primary health care approach.

xlLitzios, op. cit., p. 1887. This paper also mentions the contributions of James McGilvaray, who was the first director of the Christian Medical Commission and a former medical superintendent of the Christian Medical College at Vellore in India, where the three authors of this article currently work.

xliThe World Health Report 2001, op. cit., p. 58.

xliiA version of this paper, along with the recommendations of the Breklum consultation, was discussed at two separate Mutirão presentations at the ninth assembly of the World Council of Churches held in Porto Alegre, Brazil, from 14-23 February 2006. Participants agreed that there were many areas from the recommendations that could be taken up by local congregations; some also stressed the need for a theology that did not induce guilt in the minds of people with mental disorders and their families when they approached the church for help in their time of need.