THE NEGLECT OF PREVENTION IN PSYCHIATRY N. Sartorius, A.S. Henderson
The prevention of mental disorders has been neglected but the public health burden now is too high for this to continue. Nearly one half of all mental and neurological disorders are amenable to primary prevention. Effective measures could be applied even in countries with few resources. By and large these measuresall rely on available knowledgeand commonly involvesectors other than health. This paper calls attention to the opportunities that offer but that have been so far largely unheeded. Australian and New Zealand Journal of Psychiatry 1992; 26550453 Psychiatry has neglected prevention. Its practitioners have been occupied mainly with treatment and rehabilitation of the mentally ill. Although there is a considerable literature on primary prevention of mental disorders, most of it consists of rhetoric or proposals for what is thought possible. Few publications report the outcome of actual interventions [ 1-71. Thus Henderson et a/ [S] proposed a method for “psychological immunization” of high-risk groups, based on learning theory, but presented no evidence for its feasibility or efficacy. Raphael [2] has pointed out that much of the literature has consisted of a “call” for prevention, and that diffuse outcomes are unlikely to lead to demonstrable effects. But she did suggest that certain well-specified interventions, targeted at high-risk groups, could be shown to be effective. Goldberg and Huxley [9] have argued that primary prevention should be directed not so much at those who have been exposed to some major adversity, but ~
~
Division of Mental Health, World Health Organization, Geneva 27, Switzerland N. Sartorius MD, MA, DPM, PhD. FRANZCP, FRCPsych, Director NH&MRC Social Psychiatry Research Unit, The Australian National University, GPO Box 4, Canberra, ACT A. S . Henderson MD, DSc. FRACP, FRANZCP, FRCP, FRCPqych, Director
at those within such groups who are known to be vulnerable. Such approaches are reflected by Eisenberg [ 10,111 who, adopting a global perspective, has set out the targets for effective interventions in specific areas of neuropsychiatric morbidity. Sartorius [ 121has applied this approach to opportunities for the prevention of mental disorders in developed and developing countries. It is useful to consider possible reasons for the lack of activity in prevention, as opposed to advocacy for it. It may be that the custodial beginnings of psychiatry influenced the direction of its development away from prevention, or that the conviction that mental disorders have an immutable biological basis, and are linked to constitutional deficiencies which cannot be altered, inhibited efforts towards prevention. It may be also that the enforced distance between psychiatry and public health led the latter to exclude mental disorders from public health efforts; there is, for example, only one school of public health in the world which has a department of mental hygiene. But for what is demonstrably a major category of morbidity, the neglect of prevention is no longer defensible; the public health burden is too high. In this paper, we assess the extent of that burden, review the notion that prevention of mental disorders is impossible, and propose some initiatives.
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N. SARTORIUS, A.S. HENDERSON
The magnitude of the problem Assessment of the burden caused by mental disorder is complex because it has to involve not only an assessment of the reduction of productivity, in social and economic terms, and an estimate of the additional care which the families have to add to the contribution provided by health services, but also an assessment of the effect which the stigma linked to mental disorders will have on mentally ill persons and on their families, often over generations. Evaluation of the size and nature of the burden from problems arising in connection with illegal activities, such as taking drugs or violence, presents additional difficulties; data about them are difficult to obtain and, if available, hard to believe. A comprehensive assessment of burden has also to include the contribution of mental disorder and of factors to co-morbidity, where mental disorders appear in combination with other illnesses and complicate them or change their course. An impression of the size of the burden can be obtained from estimates [ 13) of the global prevalence of mental disorders (since co-morbidity could occur among the conditions listed here, the total numbers of people affected are not provided): - some 120 million persons in the world with mental retardation; - about 40 million persons suffering from psychoses and some 80- 100 million with depressive disorders; - the dementias of later life affecting as many as 200 per thousand of the very old; - a total of some 50 million people with epilepsy ( 3 to 4 per thousand with epilepsy in industrialised countries, and 20-30 per thousand in most parts of the developing world); - at least 5 percent of the population substantially disabled due to neurotic disorders excluding depression or personality disorders; - alcohol-related problems including dependence and other health problems such as cirrhosis, as well as problems such as violence, traffic accidents, etc.; - health problems related to drug abuse growing in size and severity in many countries; and - tobacco dependence, which has been estimated to cause 2,700,000 deaths per year. It is almost impossible to give precise estimates for the number of people with brain damage from trauma, bacterial or parasitic infections, alcohol, malnutrition or toxic chemicals, but it is certain that there are millions of them. Lastly, there is the morbidity arising
55 I
from health-damaging behaviours and life-style; violence, particularly in the home, involving women and young children: excessive risk-taking by younger persons leading to sexually-transmitted diseases; road accidents; unwanted pregnancy; and somatic symptoms resulting from distress, presenting particularly in primary care settings. The total burden arising from this diverse morbidity is clearly very large.
Preventive measures: some characteristics In considering what preventive action could be implemented, we have come to appreciate that measures for the primary prevention of mental and disorders are marked by a number of important features: I . The interventions are usually the responsibility of social sectors other than health. 2. If the interventions are the responsibility of health services, they are usually not the responsibility of psychiatric services, nor of psychiatrists. 3. Interventions which are done primarily to help the patient have a preventive effect on mental disorder in family members, even when the intervention does not change the disease in the patient (e.g. part-time hospital care of persons with dementia may contribute to the maintenance of mental health in other family members). 4. The borderline between disease, impairment and disability is often difficult to determine for mental disorders; this can make the distinction between primary and secondary prevention unclear and sometimes unnecessary. 5. Evaluation of a measure should not be expressed only in terms of reduction of incidence of a mental disorder; a more meaningful way is to express its results also in terms of improvement in quality of life, and gain for both the family and the community. 6. The amount of effort to prevent a particularly dangerous form of behaviour should be in close accord with the total number of individuals who are engaging in such a behaviour in the community. 7. Mental and neurological disorders are so high in prevalence that it is worthwhile undertaking preventive measures even when the low efficacy of such measures would speak against their implementation. If there is a measure, for example, that will stop one person in ten from smoking, it is worthwhile applying it because - in spite of its having only a 10%effect this will result in a vast decrease in the number of
Downloaded from anp.sagepub.com at University of British Columbia Library on June 27, 2015
THE NEGLECT OF PREVENTION IN PSYCHIATRY
552
Table 1. Measures likely to reduce the incidence of mental and neurological disorders
1. Advice to pregnant women not to smoke, drink alcohol or take drugs during pregnancy.
2. 3. 4. 5. 6. 7.
Advocacy of iodine supplementationfor women. Early recognition of sensory deficits in children and introduction of appropriate health service response. Preventionof injuries of the central nervous system. Education of diabetics about the prevention of consequencesof diabetic peripheral neuropathy. Management of crisis at point of primary contact with health care. Improvementof day care facilities in accordance with criteria contained in the WHO schedule for the assessment of characteristicsof day care facilities. 8. Introductionof school mental health programmes dealing with a limited number of issues. 9. Review of legislation having a direct influence in mental health of the population. This includes a review of laws concerning adoption of children, divorce, etc. and aims at identifying obsolescenceor lack of legal provisions that facilitate normal development of the child and the functioning of families. 10. Introductionof mental health skills into primary health care in order to facilitate the recognition of conditions which can lead to serious mental health problems if treated in an inappropriate manner (e.g. of mild depressive states in the elderly).
smokers, say a few million people in a country such as Russia or the USA. In addition, since one of the most powerful influences on individual life style is the behaviour of the majority, the 10% decrease may change the non-smoking minority into the non-smoking majority, and thus powerfully assist the effects of the measure, appreciably increasing its success rate. 8. Many of the mental disorders are not categorical, all-or-nothing phenomena; they are continua of abnormality ranging from conditions that do not disturb the functioning of the individual in his or her social roles to those which make acceptable performance impossible. Preventive measures can reduce the severity of the disorder and thus remove disability even if impairment is not wholly avoidable. 9. The complete list of measures set out in the Director-General's Report to the World Health Assembly 1141 may be too long for implementation, particularly in countries still reluctant to engage in work in this area. It is in such circumstances possible to envisage subsets of measures for immediate application. One example, selected for implementation by participants in a recent meeting of Eastern Mediterranean countries planning their national mental health programmes [ 151, is given in Table 1. 10. Finally, the acceptability of measures which are proposed needs to be carefully considered in relation to their affordability and technical feasibility; there are measures which can be shown to be effective, but their cost is prohibitive and/or are culturally unacceptable, and others which are cheap and acceptable but of low
efficacy. An approach that carries considerable promise is the enhancement of resilience. Rutter [ 161 and Goldberg and Huxley [9] point to this capacity of individuals who can withstand adverse experiences. Augmentation of resilience in high-risk groups is a promising strategy for primary prevention.
The next steps We can envisage three scenarios. In the first, the area of prevention remains stagnant for an indefinite period, with treatment activities continuing to receive almost exclusive emphasis. In the second, govemments would enhance research into the causes of mental disorders and, once these have been discovered, commence programmes directed specifically at such causes. In the third, action is undertaken in the immediate future, applying presently-existing knowledge. The first of these scenarios cannot readily be defended. The second is likely to postpone preventive action for a long time and, when it happens, programmes may apply to only one group of disorders. It is the third scenario which has most to commend it in the interests of public health. The documents [ 141 presented to the World Health Assembly in 1986 presented a series of measures which could be used for the primary prevention of mental and neurological disorders. According to the estimates given in these documents, as much as 50% of all mental and neurological disorders is amenable to primary prevention, at least half of the remaining
Downloaded from anp.sagepub.com at University of British Columbia Library on June 27, 2015
N. SARTORIUS, A S . HENDERSON
disorders can be subject to secondary prevention, the and the remaining 25% are often likely to benefit from measures of tertiary prevention. Most of the measures are simple to implement and involve the participation of sectors other than health.
Conclusions Recent years have brought with them the recognition that the area of morbidity relevant to psychiatry extends beyond the disorders traditionally accepted as its purview. For some, mental illness is still a term that should be used sparingly, to describe only the most serious forms of mental disorders, such as severe chronic schizophrenia; the view that less disabling forms of mental disorder should be included, however, is gaining general acceptance. The latter view, with its expanded definition of the borders of psychiatric expertise, has a significant effect on estimates of possibilities for prevention; as long as psychiatry is seen as dealing with only a small number of serious mental disorders about whose pathogenesis we know too little, possibilities for preventive action will remain meagre, and psychiatry itself will remain a custodial rather than a medical discipline. By contrast, if the borders of the territory in which psychiatry is to act are reasonably expanded, the possibility for prevention also grows, and psychiatry begins to move in step with public health efforts. In a recent paper, B. Cooper [ 171presented a simple typology of causes of mental and neurological disorders, showing that the prevention of these is easiest when their causes can be approached through the action of social services and most difficult when prevention requires major political changes and societal rearrangements. The initiatives proposed here are largely of the former type and rest on the application of presently existing knowledge.
553
References 1. Klein DC, Goldston S, eds. Primary prevention: an idea whose
time has come. Rockville, Maryland: National Institute of Mental Health, 1977. 2. Raphael B. Primary prevention: fact or fiction. Australian & New Zealand Journal of Psychiatry 1980; 14:163-173. 3. Phillips RA. Opportunities for prevention in the practice of psychiatry. American Journal of Psychiatry 1983; 140:389-395. 4. Eisenberg L. Prevention: rhetoric and reality. Journal of the Royal Society of Medicine 1984; 77:268-280. 5. Primary prevention in mental health: an annotated bibliography. Rockville, Maryland: National Institute of Mental Health, 1985. 6. Marlow EHA. Weinberg RB, eds. Is mental illness preventable? New York: Human Sciences Press, 1985; 5:4. 7. Newton J . Preventing mental illness. London: Routledge and Kegan Paul. 1988. 8. Henderson AS, Montgomery IM, Williams CL. Psychological immunization: a proposal for preventive psychiatry. Lancet 1972; 1:1111-1113. 9. Goldberg D, Huxley P. Common mental disorders. A bio-social model. London: Routledge, 1992. 10. Eisenberg L. A research framework for evaluating the promotion of mental health and the prevention of mental illness. Public Health Reports 1981; 96:3-19. 11. Eisenberg L. Preventing mental, neurological and disorders. World Health Forum 1987; 8:245-253. 12. Sartorius N. The World Health Organization’s views on the prevention of mental disorders in developed and developing countries. In: Cooper B, Helgason T, eds. Epidemiology and the prevention of mental disorders. London: Routledge. 1989. 13. World Health Organization. Prevention of mental, neurological and disorders. WHO, Geneva, 1988. 14. World Health Organization. Prevention of mental, neurological and disorders. Report by the Director-General (document A39/9) 1986. 15. World Health Organization. Report on the second intercountry meeting on progress achieved in national mental health programmes. Nicosia, Cyprus, 16-20 July 1990. WHO Regional Office for the Eastern Mediterranean, 1991. 16. Rutter, M. Resilience in the face of adversity. British Journal of Psychiatry 1985; 147598-61 1. 17. Cooper B. Epidemiology and prevention in the mental health field. Social Psychiatry and Psychiatric Epidemiology 1990 25:915.
Downloaded from anp.sagepub.com at University of British Columbia Library on June 27, 2015
The prevention of mental disorders has been neglected but the public health burden now is too high for this to continue. Nearly one half of all mental and neurological disorders are amenable to primary prevention. Effective measures could be applied even in countries with few resources. By and large these measuresall rely on available knowledgeand commonly involvesectors other than health. This paper calls attention to the opportunities that offer but that have been so far largely unheeded. Australian and New Zealand Journal of Psychiatry 1992; 26550453 Psychiatry has neglected prevention. Its practitioners have been occupied mainly with treatment and rehabilitation of the mentally ill. Although there is a considerable literature on primary prevention of mental disorders, most of it consists of rhetoric or proposals for what is thought possible. Few publications report the outcome of actual interventions [ 1-71. Thus Henderson et a/ [S] proposed a method for “psychological immunization” of high-risk groups, based on learning theory, but presented no evidence for its feasibility or efficacy. Raphael [2] has pointed out that much of the literature has consisted of a “call” for prevention, and that diffuse outcomes are unlikely to lead to demonstrable effects. But she did suggest that certain well-specified interventions, targeted at high-risk groups, could be shown to be effective. Goldberg and Huxley [9] have argued that primary prevention should be directed not so much at those who have been exposed to some major adversity, but ~
~
Division of Mental Health, World Health Organization, Geneva 27, Switzerland N. Sartorius MD, MA, DPM, PhD. FRANZCP, FRCPsych, Director NH&MRC Social Psychiatry Research Unit, The Australian National University, GPO Box 4, Canberra, ACT A. S . Henderson MD, DSc. FRACP, FRANZCP, FRCP, FRCPqych, Director
at those within such groups who are known to be vulnerable. Such approaches are reflected by Eisenberg [ 10,111 who, adopting a global perspective, has set out the targets for effective interventions in specific areas of neuropsychiatric morbidity. Sartorius [ 121has applied this approach to opportunities for the prevention of mental disorders in developed and developing countries. It is useful to consider possible reasons for the lack of activity in prevention, as opposed to advocacy for it. It may be that the custodial beginnings of psychiatry influenced the direction of its development away from prevention, or that the conviction that mental disorders have an immutable biological basis, and are linked to constitutional deficiencies which cannot be altered, inhibited efforts towards prevention. It may be also that the enforced distance between psychiatry and public health led the latter to exclude mental disorders from public health efforts; there is, for example, only one school of public health in the world which has a department of mental hygiene. But for what is demonstrably a major category of morbidity, the neglect of prevention is no longer defensible; the public health burden is too high. In this paper, we assess the extent of that burden, review the notion that prevention of mental disorders is impossible, and propose some initiatives.
Downloaded from anp.sagepub.com at University of British Columbia Library on June 27, 2015
N. SARTORIUS, A.S. HENDERSON
The magnitude of the problem Assessment of the burden caused by mental disorder is complex because it has to involve not only an assessment of the reduction of productivity, in social and economic terms, and an estimate of the additional care which the families have to add to the contribution provided by health services, but also an assessment of the effect which the stigma linked to mental disorders will have on mentally ill persons and on their families, often over generations. Evaluation of the size and nature of the burden from problems arising in connection with illegal activities, such as taking drugs or violence, presents additional difficulties; data about them are difficult to obtain and, if available, hard to believe. A comprehensive assessment of burden has also to include the contribution of mental disorder and of factors to co-morbidity, where mental disorders appear in combination with other illnesses and complicate them or change their course. An impression of the size of the burden can be obtained from estimates [ 13) of the global prevalence of mental disorders (since co-morbidity could occur among the conditions listed here, the total numbers of people affected are not provided): - some 120 million persons in the world with mental retardation; - about 40 million persons suffering from psychoses and some 80- 100 million with depressive disorders; - the dementias of later life affecting as many as 200 per thousand of the very old; - a total of some 50 million people with epilepsy ( 3 to 4 per thousand with epilepsy in industrialised countries, and 20-30 per thousand in most parts of the developing world); - at least 5 percent of the population substantially disabled due to neurotic disorders excluding depression or personality disorders; - alcohol-related problems including dependence and other health problems such as cirrhosis, as well as problems such as violence, traffic accidents, etc.; - health problems related to drug abuse growing in size and severity in many countries; and - tobacco dependence, which has been estimated to cause 2,700,000 deaths per year. It is almost impossible to give precise estimates for the number of people with brain damage from trauma, bacterial or parasitic infections, alcohol, malnutrition or toxic chemicals, but it is certain that there are millions of them. Lastly, there is the morbidity arising
55 I
from health-damaging behaviours and life-style; violence, particularly in the home, involving women and young children: excessive risk-taking by younger persons leading to sexually-transmitted diseases; road accidents; unwanted pregnancy; and somatic symptoms resulting from distress, presenting particularly in primary care settings. The total burden arising from this diverse morbidity is clearly very large.
Preventive measures: some characteristics In considering what preventive action could be implemented, we have come to appreciate that measures for the primary prevention of mental and disorders are marked by a number of important features: I . The interventions are usually the responsibility of social sectors other than health. 2. If the interventions are the responsibility of health services, they are usually not the responsibility of psychiatric services, nor of psychiatrists. 3. Interventions which are done primarily to help the patient have a preventive effect on mental disorder in family members, even when the intervention does not change the disease in the patient (e.g. part-time hospital care of persons with dementia may contribute to the maintenance of mental health in other family members). 4. The borderline between disease, impairment and disability is often difficult to determine for mental disorders; this can make the distinction between primary and secondary prevention unclear and sometimes unnecessary. 5. Evaluation of a measure should not be expressed only in terms of reduction of incidence of a mental disorder; a more meaningful way is to express its results also in terms of improvement in quality of life, and gain for both the family and the community. 6. The amount of effort to prevent a particularly dangerous form of behaviour should be in close accord with the total number of individuals who are engaging in such a behaviour in the community. 7. Mental and neurological disorders are so high in prevalence that it is worthwhile undertaking preventive measures even when the low efficacy of such measures would speak against their implementation. If there is a measure, for example, that will stop one person in ten from smoking, it is worthwhile applying it because - in spite of its having only a 10%effect this will result in a vast decrease in the number of
Downloaded from anp.sagepub.com at University of British Columbia Library on June 27, 2015
THE NEGLECT OF PREVENTION IN PSYCHIATRY
552
Table 1. Measures likely to reduce the incidence of mental and neurological disorders
1. Advice to pregnant women not to smoke, drink alcohol or take drugs during pregnancy.
2. 3. 4. 5. 6. 7.
Advocacy of iodine supplementationfor women. Early recognition of sensory deficits in children and introduction of appropriate health service response. Preventionof injuries of the central nervous system. Education of diabetics about the prevention of consequencesof diabetic peripheral neuropathy. Management of crisis at point of primary contact with health care. Improvementof day care facilities in accordance with criteria contained in the WHO schedule for the assessment of characteristicsof day care facilities. 8. Introductionof school mental health programmes dealing with a limited number of issues. 9. Review of legislation having a direct influence in mental health of the population. This includes a review of laws concerning adoption of children, divorce, etc. and aims at identifying obsolescenceor lack of legal provisions that facilitate normal development of the child and the functioning of families. 10. Introductionof mental health skills into primary health care in order to facilitate the recognition of conditions which can lead to serious mental health problems if treated in an inappropriate manner (e.g. of mild depressive states in the elderly).
smokers, say a few million people in a country such as Russia or the USA. In addition, since one of the most powerful influences on individual life style is the behaviour of the majority, the 10% decrease may change the non-smoking minority into the non-smoking majority, and thus powerfully assist the effects of the measure, appreciably increasing its success rate. 8. Many of the mental disorders are not categorical, all-or-nothing phenomena; they are continua of abnormality ranging from conditions that do not disturb the functioning of the individual in his or her social roles to those which make acceptable performance impossible. Preventive measures can reduce the severity of the disorder and thus remove disability even if impairment is not wholly avoidable. 9. The complete list of measures set out in the Director-General's Report to the World Health Assembly 1141 may be too long for implementation, particularly in countries still reluctant to engage in work in this area. It is in such circumstances possible to envisage subsets of measures for immediate application. One example, selected for implementation by participants in a recent meeting of Eastern Mediterranean countries planning their national mental health programmes [ 151, is given in Table 1. 10. Finally, the acceptability of measures which are proposed needs to be carefully considered in relation to their affordability and technical feasibility; there are measures which can be shown to be effective, but their cost is prohibitive and/or are culturally unacceptable, and others which are cheap and acceptable but of low
efficacy. An approach that carries considerable promise is the enhancement of resilience. Rutter [ 161 and Goldberg and Huxley [9] point to this capacity of individuals who can withstand adverse experiences. Augmentation of resilience in high-risk groups is a promising strategy for primary prevention.
The next steps We can envisage three scenarios. In the first, the area of prevention remains stagnant for an indefinite period, with treatment activities continuing to receive almost exclusive emphasis. In the second, govemments would enhance research into the causes of mental disorders and, once these have been discovered, commence programmes directed specifically at such causes. In the third, action is undertaken in the immediate future, applying presently-existing knowledge. The first of these scenarios cannot readily be defended. The second is likely to postpone preventive action for a long time and, when it happens, programmes may apply to only one group of disorders. It is the third scenario which has most to commend it in the interests of public health. The documents [ 141 presented to the World Health Assembly in 1986 presented a series of measures which could be used for the primary prevention of mental and neurological disorders. According to the estimates given in these documents, as much as 50% of all mental and neurological disorders is amenable to primary prevention, at least half of the remaining
Downloaded from anp.sagepub.com at University of British Columbia Library on June 27, 2015
N. SARTORIUS, A S . HENDERSON
disorders can be subject to secondary prevention, the and the remaining 25% are often likely to benefit from measures of tertiary prevention. Most of the measures are simple to implement and involve the participation of sectors other than health.
Conclusions Recent years have brought with them the recognition that the area of morbidity relevant to psychiatry extends beyond the disorders traditionally accepted as its purview. For some, mental illness is still a term that should be used sparingly, to describe only the most serious forms of mental disorders, such as severe chronic schizophrenia; the view that less disabling forms of mental disorder should be included, however, is gaining general acceptance. The latter view, with its expanded definition of the borders of psychiatric expertise, has a significant effect on estimates of possibilities for prevention; as long as psychiatry is seen as dealing with only a small number of serious mental disorders about whose pathogenesis we know too little, possibilities for preventive action will remain meagre, and psychiatry itself will remain a custodial rather than a medical discipline. By contrast, if the borders of the territory in which psychiatry is to act are reasonably expanded, the possibility for prevention also grows, and psychiatry begins to move in step with public health efforts. In a recent paper, B. Cooper [ 171presented a simple typology of causes of mental and neurological disorders, showing that the prevention of these is easiest when their causes can be approached through the action of social services and most difficult when prevention requires major political changes and societal rearrangements. The initiatives proposed here are largely of the former type and rest on the application of presently existing knowledge.
553
References 1. Klein DC, Goldston S, eds. Primary prevention: an idea whose
time has come. Rockville, Maryland: National Institute of Mental Health, 1977. 2. Raphael B. Primary prevention: fact or fiction. Australian & New Zealand Journal of Psychiatry 1980; 14:163-173. 3. Phillips RA. Opportunities for prevention in the practice of psychiatry. American Journal of Psychiatry 1983; 140:389-395. 4. Eisenberg L. Prevention: rhetoric and reality. Journal of the Royal Society of Medicine 1984; 77:268-280. 5. Primary prevention in mental health: an annotated bibliography. Rockville, Maryland: National Institute of Mental Health, 1985. 6. Marlow EHA. Weinberg RB, eds. Is mental illness preventable? New York: Human Sciences Press, 1985; 5:4. 7. Newton J . Preventing mental illness. London: Routledge and Kegan Paul. 1988. 8. Henderson AS, Montgomery IM, Williams CL. Psychological immunization: a proposal for preventive psychiatry. Lancet 1972; 1:1111-1113. 9. Goldberg D, Huxley P. Common mental disorders. A bio-social model. London: Routledge, 1992. 10. Eisenberg L. A research framework for evaluating the promotion of mental health and the prevention of mental illness. Public Health Reports 1981; 96:3-19. 11. Eisenberg L. Preventing mental, neurological and disorders. World Health Forum 1987; 8:245-253. 12. Sartorius N. The World Health Organization’s views on the prevention of mental disorders in developed and developing countries. In: Cooper B, Helgason T, eds. Epidemiology and the prevention of mental disorders. London: Routledge. 1989. 13. World Health Organization. Prevention of mental, neurological and disorders. WHO, Geneva, 1988. 14. World Health Organization. Prevention of mental, neurological and disorders. Report by the Director-General (document A39/9) 1986. 15. World Health Organization. Report on the second intercountry meeting on progress achieved in national mental health programmes. Nicosia, Cyprus, 16-20 July 1990. WHO Regional Office for the Eastern Mediterranean, 1991. 16. Rutter, M. Resilience in the face of adversity. British Journal of Psychiatry 1985; 147598-61 1. 17. Cooper B. Epidemiology and prevention in the mental health field. Social Psychiatry and Psychiatric Epidemiology 1990 25:915.
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