A war as noble as a battle for one's country

Norman Sartorius is ideally placed to survey the global position and issues for psychiatry, having been president of the World Psychiatric Association and director for mental health at the World Health Organisation. The essays in this book are collected under three themes: the context of health and medicine, the relationship between medicine and mental health, and psychiatry and mental health programmes.

Sartorius provides justification for the argument that fighting for mental health needs to be sustained effort for ethical and practical reasons. Effective treatments exist for the millions who suffer from mental disorders. He is passionate about the de-stigmatisation of psychiatry. He consistently restores value to the perspective of individuals and carers:

"Years of looking after a severely ill person deserves just as much (if not more) praise as being wounded on a battlefield protecting one's country."

The war against mental disorders and their social and economic consequences involves three battlefields. Starting at the highest level of mental-health programmes, Sartorius emphasises the principles of equity and social inclusion, expanding the delivery of these rights to their improvement of the social capital of society. He dissects the impact of mental-health programmes, challenging developmental dogmas, explaining the de-synchrony of research and policy, and how staggering levels of need in mental health repeatedly command low priority. His arguments deserve serious attention from programme planners.

The next battlefield is the borderland between mental health and general medicine, including primary care. There has been a march towards primary care-level responsibility and treatment for illnesses that have traditionally been the domain of specialist services. Why has this been so difficult to achieve for mental-health services? The answer lies in primary and specialist care practices. The stigma and vested interests that sustain a two-tier psychiatry are concealed in arguments about technological expertise and resources. The elegance of specialist centres contrasts with the squalor of general provision. The project of de-institutionalisation has time and again become unstuck with underinvestment in comprehensive community alternatives. Transfer of responsibility involves transfer of power and resources.

Sartorius concludes that psychiatrists are not ardent supporters of the delegation of mental-health care to general services. Change will depend more on emotional and social pressures than public-health imperatives.

Fundamental to this change is a wider societal acceptance of mental disorder.

Sartorius repeatedly draws out the distinction between psychiatry and mental-health programmes. The simple fact that "psychiatry" and "mental-health" services are not interchangeable terms is not only confusing for some, it presents major conceptual, ethical and practical problems for practitioners and society in general. The parameters of need deriving from working definitions of illness, sickness and disease are complex. In comparing the vices of psychiatry to the seven deadly sins, he is refreshingly honest about the misplaced pride of psychiatrists in claiming to have a comprehensive system of operational criteria for the definition of mental disorders. Categories that were produced by a measure of international consensus have somehow assumed the status of truth. They ignore uncertainty and become "real" diseases, which leads to a self-perpetuating cycle of epidemiological, causal and therapeutic research. The resulting intellectual arrogance of psychiatry has been one of its greatest sins. This false claim of certainty sits uneasily with the interdisciplinary wars within psychiatry. Sartorius writes: "Unless they (psychiatrists) change their ways, mental-health programmes will continue their arduous and slow development for a long time."

Sartorius is aware that most mental-health workers are fighting a battle on their own doorstep. They are not coordinating World Health Organisation programmes. This book dignifies those who struggle with illness or care in families. Winning a war requires an in-depth appraisal of the strength of one's enemy. Sartorius reminds us that the enemy is often our own and our society's low regard for better mental health.

Marcellino Smyth is professor of social and community psychiatry, University of Central England.