Abstract
In many countries Norman Sartorius would be the most well-known and influential psychiatrist of this generation. This book is a compilation of his papers. As a result the flow of the book is somewhat disjointed. However, the text is written in the conversational style, which makes for easy reading. The focus is less about clinical care of patients and more about policy, services, population mental health and social and economic development, especially as it applies to emerging market economies.
I like the way Sartorius thinks. He writes from a unique perspective and provides what many texts lack – wisdom, in addition to information. He has distinguished himself as a clinician, scientist and bureaucrat and in this book we gain insights into the accumulated wisdom of his decades of experience.
Sartorius takes a very broad definition of mental health and the integral role good mental health can play in a socially cohesive and healthy civil society. His understanding of developing countries is evident in his discussion of the problems of social and economic development and the contribution mental health can make to these. He challenges many of the dogmas of development. Sartorius ventures into areas such as the role of health, education, population growth and research in promoting social and economic growth. He has a good grasp of how public policy is developed and the limited capacity of researchers and clinicians to influence it.
Sartorius also argues that vagueness of the fundamental concepts of psychiatry retards the growth of the discipline and contributes to the low priority given to mental health in most developing countries. He discusses moral, legal and ethical issues; the confusion surrounding the meanings of concepts such as illness, behaviour, disease and sickness; and needs as expressed by the patients, families and the community.
Further, Sartorius argues that mental health and psychiatry has failed to clearly describe the effectiveness of their interventions; failed to translate knowledge into techniques that can be used by non-mental health specialists; and bemoans the lack of motivation of mental health professionals to work on matters related to socioeconomic development.
Sartorius is an advocate for the close alignment between psychiatry and medicine but recognizes the barriers and dangers associated with this. He enters the debate about whether mental health services can and should be delivered in primary health care. He concludes by supporting this policy. However, he is critical of the way in which primary health care services have been planned, financed and delivered. He argues for changes in the primary health care movement internationally to address rapidly changing disease epidemiology, demography and sociopolitical environments. He advocates for general medical services (including primary health care) to be strongly supported by high quality specialist mental health services. Getting this balance right is a challenge for all countries, including Australia.
Sartorius wades into problems with terminology. He gives a list of words that he ‘hates’ because they are misleading, unnecessary or harmful. These are Western (as in the Western world), Third World, affordable, consumers, schizophrenics and compliance. Sartorius also argues for an expansion of the concept of rehabilitation and suggests the word ‘enabling’, while ‘not the right word’ better describes what needs to take place after a person has been affected by a mental illness. There is also an interesting chapter on what Sartorius calls the ‘seven vices of psychiatry’, which he discusses under headings of the seven deadly sins.
Sartorius also gives his view of the basis for planning psychiatric services, which I found particularly interesting. He argues the case for aged care services, preventative services, the involvement of self-help and family organizations in service delivery, and devotes the final chapter of the book to psychiatry in developing countries.
Of particular interest to some readers is a chapter devoted to the World Health Organization; Sartorius was Director of the Division of Mental Health from 1977 to 1993.
The book is challenging and, in parts, fascinating. While much may not seem immediately relevant to the day-to-day work of a psychiatrist, this is in fact a strength. The day-to-day work of psychiatrists could be much more effective if we could rise to the challenges put forward in this book.