Mental Health Leadership in a Changing World

1. Mental Health Leadershipin a Changing World Harry Minas Centre for International Mental Health The University of Melbourne

2. Traditional role of psychiatrists • Psychiatrists have traditionally worked on providing the best quality clinical care to the people with the most severe mental disorders • In most countries this has meant a focus on hospital-based care for people with psychotic and severe affective disorders • Psychiatric training has focused on the development of clinical skills for this limited patient group • Psychiatrists have generally left policy and service design issues to others • Research (and research skills) has been focused on basic science of mental disorders and clinical interventions, with little interest in cost- effectiveness or in research on health systems 3% severe mental disorders

3. Expanded roles for psychiatrists • Epidemiological work has increasingly focused on the high prevalence of depression, anxiety and other disorders in populations, on the high population burden due to these disorders, and the fact that most people with these disorders are untreated or poorly treated • In addition, problems with large mental institutions, and human rights concerns, have increased the pressure to move the focus from hospital-based to community-based systems • The role of psychiatrists has shifted from clinical specialist to leader of multi-disciplinary teams and negotiator with governments, families, clinician colleagues working in the community (such as general practitioners), NGOs, and other (non-health) sectors 20% total mental disorder 3% severe mental disorders

4. Expanded roles for psychiatrists • A focus on population mental health requires that psychiatrists focus on mental health promotion, illness (and suicide) prevention, and early intervention • This requires a broader community leadership role and working with community groups, the media and governments 20% total mental disorder Population mental health 3% severe mental disorders

5. The process through which an individual intentionally influences another individual or, more usually, a group in order to accomplish a goal. Leadership involves defining and communicating a vision for the future, based on some core and explicit values, aligning people with that vision, and inspiring them to work to make it happen, despite obstacles. Transforming the current reality into the imagined future. Leadership is always focused on change, from how things are to how they ought to be. Leadership

6. Change is constant What may have been acceptable in the past is less acceptable now. Most people with mental illness: receive no treatment are excluded from the benefits of citizenship work, education, decent accommodation, respect have their rights neglected or abused have no voice decisions are made for them by others Mental health service = Mental Hospital Now a wide range of different types of service are expected to meet a wide range of different needs Change

7. Effective leadership infects others with: Enthusiasm Energy Drive Confidence Determination Belief that the common goal of the group can be achieved The leader Articulates the group’s mission Gives clarity and direction to the activities of the group Keeps the group focused and on track Leadership

8. Leadership - in its simplest representation ETHICS Service to others REALITY Clearanalysis of current problems VISION Compellingimage of what is desirable and possible Strategy COURAGE Act with sustained initiative

9. This is the most critical, and most neglected, part of achieving mental health system reform Mental health is a low priority Indonesia spends 1% of the total health budget on mental health (WHO Atlas 2005) Mental illness has to become an important national problem Human rights Economic burden Barrier to social and economic development Key public health problem Those who have the power to define what are the important problems get the resources Security, Global warming There is not yet a sufficiently clear and coherent definition of the problem of mental health at national and international levels Problem Definition REALITY Clearanalysis of current problems

10. We know that mental illness: accounts for a large proportion of the total burden of disease, and that this proportion will increase is the biggest cause of disability imposes a huge economic burden on society in terms of lost productivity, etc. can be a substantial a barrier to economic and social development associated with descent into poverty Social and economic burden

11. Mental disorders and mental health problems are risk factors for: Non-communicable disease Cardiovascular disease Diabetes Communicable disease HIV-AIDS Injury Deliberate self-harm and suicide Maternal depression and child development Child malnutrition, stunting, impaired development Comorbidity Complicates help-seeking, diagnosis and treatment, and Adversely influences prognosis Public health problem

12. Human Rights Problem Is this what we wantmental services to be? In many parts of theworld this isthe current reality

13. We have: a better understanding of mental illness than ever before effective and affordable treatments evidence for what kinds of service are most effective in meeting the needs of people with mental illness evidence for what kinds of services people with mental illness, and their families, prefer But: We are not making effective use of this knowledge for the benefit of people with mental illness Solutions?

14. Mental Health Services should be: Effective - achieve clinical outcomes Appropriate - relevant to needs Efficient - cost-effective Responsive - protect rights & consider preferences Accessible and equitable - geographic and financial accessibility, provided according to need Safe - for patients, staff, community Continuous - across time, programs, organisations Capable - knowledgeable and skilled staff Is this vision shared by all relevant stakeholders? or Do different stakeholder groups have very different ideas about what the most important problems are and what a future mental health system should be? Vision: What MH services should be VISION Compellingimage of what is desirable and possible

15. Test of agreement on Vision for the future

16. Leadership • The highest priority issues in developing a leadership strategy are: • Defining mental health as an important problem for governments • Achieving agreement among key stakeholder groups about the core elements of the vision for the future • Demonstrating that solutions are available and politically feasible REALITY Clearanalysis of current problems VISION Compellingimage of what is desirable and possible Strategy

17. Governments Ministries of Health, Finance, Social Services, Employment, etc. Stakeholders The mental health sector is very broad, with many stakeholders: • General community • Patients and their families • Service Providers • Mental Health Professionals (and their associations) • Psychiatrists, Psychologists, Nurses, Social workers, etc. • General Health Professionals (and their associations) • Health Institutions • Public and private hospitals, Health insurance organisations (public and private), Pharmaceutical industry, etc. • Universities and training colleges

18. Governments Ministries of Health, Finance, Social Services, Employment, etc. Stakeholders The mental health sector is very broad, with many stakeholders: • General community • Patients and their families • Service Providers • Mental Health Professionals (and their associations) • Psychiatrists, Psychologists, Nurses, Social workers, etc. • General Health Professionals (and their associations) • Health Institutions • Public and private hospitals, Health insurance organisations (public and private), Pharmaceutical industry, etc. • Universities and training colleges Coherent Demands

19. The three key stakeholder groups that need to persuade government to improve mental health services are: The general community (issues of community safety, cost of services to community) People with mental illness and their families (issues of accessibility, quality and affordability of services) Service providers (Mental health professionals are only a small part of this broad group) A mechanism is needed for these groups to talk to each other, to discover what they agree about, and to put on hold what they disagree about Who will do this? ? National NGO with representation of all the key stakeholder groups An example is the Mental Health Council of Australia If there is no agreement between the three groups (and the sub-groups within them) about what needs to be done then taking any action is a risk for governments When there is no clear way forward governments will prefer to do nothing Stakeholders

20. Leadership REALITY Clearanalysis of current problems VISION Compellingimage of what is desirable and possible Strategy COURAGE Act with sustained initiative • Taking sustained action to achieve agreement among key stakeholders about the core elements of the vision for the future is a key leadership task

21. Leadership • Act with integrity in the interests of people with mental illness ETHICS Service to others REALITY Clearanalysis of current problems VISION Compellingimage of what is desirable and possible Strategy Becomes the new Reality - with new problems to be solved COURAGE Act with sustained initiative • Taking sustained action to achieve agreement among key stakeholders about the core elements of the vision for the future is a key leadership task

22. A key obstacle to mental health system reform and development is the lack of a unified voice among key stakeholder groups about: What the most important problems are What the future mental health system should be A key opportunity for psychiatrists is to lead in developing this consensus and in taking a common view to governments about what must be done Obstacles and Opportunities