World Federation for Mental Health

In Psychiatry and Mental Health, physical exercise and sport have been neglected as essential tools in preventing the occurrence of mental disorders, in improving health and mental health, and in treating mental patients. This paper advocates for a better knowledge of this field by mental health workers in the best interest of care of mental patients.

The Society of Critical Care Medicine (SCCM) envisions a world in which all critically ill and injured persons receive care from a present, integrated team of dedicated trained intensivists and critical care specialists. Multiprofessional teams use knowledge, technology, and compassion to provide timely, effective, safe, efficient, and equitable patientcentered care (1).? The shorthand version is the organization?s trademark ?Right Care, Right Now? that in the society?s vision ?is best provided by an integrated team of dedicated experts directed by a trained and present physician credentialed in critical care (an intensivist). Right Care, Right Now means the right care is delivered at exactly the right moment to achieve optimal patient outcomes (1).? The following collaboration between international authors is not just opportunity to reflect on SCCM?s rich history but highlights the fundamental role Critical Care Medicine (CCM) has played in defining today?s healthcare paradigm: multidisciplinary, multiprofessional, team-based, and patient-focused care. Here, we aim to explore the evolution of ?international? critical care and help to understand our current standing in the specialty?s history.

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Abstract The argument of this paper is that the legacy of “ecclesia semper reformanda” (churches in a continued reformation and renewal) in Africa should not only transform the theological perspective of the Lutheran communion, but also take stock of the diaconal, social, economic and political realities of its members. In other words, a theology done in Africa needs tools and methodologies that are more comprehensive.

The aim of the study was to identify optimal muscle selection patterns for onabotulinumtoxinA treatment of poststroke lower-limb spasticity. Adults with poststroke lower-limb spasticity (ankle Modified Ashworth Scale ≥3) were randomized to onabotulinumtoxinA (300 U, mandatory ankle plantar flexors; ≤100 U, optional lower-limb muscles) or placebo. Post hoc analysis assessed the impact of muscle selection patterns on ankle Modified Ashworth Scale and physician-assessed Clinical Global Impression of Change based on change from baseline to average of weeks 4/6 versus placebo. Among 468 patients randomized, onabotulinumtoxinA improved ankle Modified Ashworth Scale (-0.81 vs -0.61, P = 0.01) and Clinical Global Impression of Change (0.86 vs 0.65, P = 0.012) versus placebo. Injection of mandatory muscles alone was not sufficient in improving ankle Modified Ashworth Scale (P = 0.255) or Clinical Global Impression of Change (P = 0.576) versus placebo but was adequate 24 mos or less after stroke (Modified Ashworth Scale, -1.13 vs -0.62, P = 0.019; Clinical Global Impression of Change, 1.24 vs 0.68, P = 0.006). Additional injections into toe muscles (flexor digitorum longus, flexor hallucis longus) improved ankle Modified Ashworth Scale (-0.98 vs -0.52, P = 0.002) and Clinical Global Impression of Change (0.80 vs 0.38, P = 0.023) versus placebo regardless of time since stroke. OnabotulinumtoxinA was well tolerated, with no new safety findings. Post hoc analyses suggested additional injections of onabotulinumtoxinA into toe flexors improved ankle Modified Ashworth Scale and Clinical Global Impression of Change scores versus mandatory muscles alone overall and with treatment initiation more than 24 mos after stroke.

By 2050, the world population over the age of 60 is expected to reach two billion.1 A rapid growth of older people will occur in low- and middle-income countries (LMIC) with huge consequences for these vulnerable economies.2 Many people live a long and happy life without any mental health problems, despite the all too prevalent impression of elderly people being sad, slow and forgetful, mental disorders are not an inevitable consequence of ageing. Nevertheless, one of the possible negative consequences of the rapid ageing of the global population is the increase in the number of people with mental disorders, which will soon overwhelm the mental health systems in all countries.2 More than 20% of people aged 55 or older may have some type of mental health problem.3 Biological changes may interfere with the brain's functioning, social changes can lead to isolation or worthlessness and somatic diseases are often important contributory factors too. Mental disorders may exacerbate the symptoms and functional disabilities associated with medical illnesses and increase the use of healthcare resources, length of hospital stay and overall cost of care.4 Mental health problems can have a high impact on an older person's ability to carry out basic daily living activities, reducing their independency, autonomy and quality of life. The first step to reduce these negative consequences is simply to make a diagnosis. Unfortunately, too often mental health problems are undiagnosed and untreated and many older people struggle on without proper help or any help at all.4 Today's older adult population is not likely to acknowledge mental illness or to access mental health services. Many stigmas exist regarding the meaning of mental illness. Many elderly people view mental illness as a sign of weakness and are unlikely to admit to experiencing problems, especially when they fear loss of independence. Too many people consider the symptoms of dementia and depression as a normal part of ageing. Many older people also lack the availability of, and access to, services.5 Other difficulties concern the workforce: few mental health providers have had specialised training in providing care for older adults and many come with a set of societal-transmitted biases themselves. This therapeutic pessimism of health professionals means they believe that older people cannot change and that it is too late for psychiatric care to be administered. As a result, there are few investments in the development of policies, strategies, programmes and services for older persons with mental health problems.2 It will be very difficult for all countries, no matter what their respective income levels are, to assure the development of a specific workforce to treat and care for older people with mental health disorders at the same rate that this group is growing. Other existing resources have to be used; primary care becomes mandatory. The mental health and wellbeing of older people was chosen by the World Federation for Mental Health as the theme for the World Mental Health Day 2013. This is a very good occasion to reflect on the global situation of older people with mental disorders around the globe. This issue of Mental Health in Family Medicine is a contribution to this reflection and an affirmation that the collaboration between old age mental health professionals and primary care teams is not only possible, it is absolutely necessary. Shulin Chen et al develop in their article how, in China, and in particular rural China, it is necessary to develop and test approaches to the care for patients with dementia. Evidence-based collaborative care models for dementia, depression and other chronic diseases that have been developed in some Western countries serve as a basis for the discussion of innovative approaches to the management of dementia in China, with particular focus on its implementation in the primary care system. Research into mental health issues in general practice is often limited by several issues despite the importance of developing knowledge in this field. Recruitment rates of general practitioners (GPs) to carry out research vary widely. This may be related to the ability of studies to incorporate incentives for GPs and minimise barriers to participation. Chris Fox et al make suggestions to optimise primary care for people with dementia. Authors consider key areas in primary care regarding the diagnosis of dementia. Issues surrounding assessment, policy and incentives are considered. In addition, the relevance of non-medication approaches for dementia in primary care, which aim to enhance or maintain quality of life, is deliberated. Key issues about primary care medication management are considered and relevant therapeutic strategies that improve outcomes by linking primary and secondary healthcare services with social care needs are weighed up. A key aspect of such a collaborative approach is to support informal carers in optimising medication. Nogueira et al focus on the development of a liaison old age psychiatry (LOAP) facility. Elderly patients occupy up to 65% of acute hospital beds and a significant proportion of them present with a comorbid psychiatric condition such as depression, delirium or dementia. A LOAP service may provide psychiatric consultation in medical and surgical settings, improving at the same time the knowledge and expertise of general ward staff. A LOAP service may play an important role to effectively reduce the overutilisation and consumption of health resources through the early recognition of these conditions, effective management and prevention of adverse outcomes, and articulation with outpatient clinics, community mental health teams and day-care centres. Syahnaz Mohd Hashim et al develop the role of primary care in the bereavement of older people. This bereavement can lead to psychological illness such as depression. While most people are able to come to terms with their grief without any intervention, some vulnerable people are not. Early recognition of elderly people with bereavement-related depressive illness is a priority. Primary care physicians need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the caregiver's burden and suffering. Henry Brodaty et al used a sample of GPs from the Sydney intervention and control groups from the Ageing in General Practice ‘Detection and Management of Dementia’ project, as well as GPs who had refused participation, to determine incentives and barriers to participating in research. Authors detected the contributing factors as incentives and barriers to the success of this project and they make suggestions for how to improve future recruitment of GPs. Boadie W Dunlop et al highlight frequently over-looked aspects of the care of older patients who present with depression and anxiety in primary care. Chief among these aspects is the consideration of a thorough differential diagnosis, particularly bipolar disorder, psychotic disorders, dementia and substance abuse, each of which requires specific treatment approaches. They conclude that judicious use of benzodiazepine and appropriate referrals to psychotherapy can contribute to optimal treatment outcomes. All these articles confirm that the shifting of focus to the ageing will have profound consequences for the workforce, healthcare systems, informal and formal caregiver capacity and society in general, and will require more and better strategies to ensure good mental health and wellbeing in the growing older population. The negative stereotypes and attitudes regarding ageing and older people must be stopped. The balance between vulnerability and resilience is central to mental health promotion and certain groups with specific burdens face a higher risk of poorer mental health. Older women often face risks that increase their vulnerability, both as sufferers of mental health problems and caregivers. Policies to support them and interventions to prevent mental health problems and isolation in older women must be strengthened.7 In conclusion, the promotion of healthy ageing in all its aspects is an important role for all societies. Early recognition, diagnosis and treatment of mental disorders that are common in old age are important to prevent suffering and disabilities. Care for older adults with mental illnesses requires sensitivity and observational and relational skills in order to help the older person achieve and maintain the highest possible level of functioning and wellbeing. Those who care for older people should always be protected and supported in their tasks everywhere. All these interventions can be efficiently realised in primary care. All these actions together can certainly contribute to better mental health in old age.

The increasing evidence base for cost-effective interventions and a fledgling advocacy effort have given momentum to mental health becoming a global priority. The contention of this editorial is that we are at a tipping point if we can exploit the opportunities that will be afforded to mental health professionals and advocates in the next year or two. The missing links are the development of consensus among mental health stakeholders, the formation of coalitions and partnerships with both advocates and policy-makers, and the mobilisation of a stronger advocacy effort built around consumer and family member ‘voice’ and empowerment.

Health care is deficient in many parts of the world, in money, facilities and manpower. In wealthy countries, the costs and complexity of health care are increasing unsustainably. Nevertheless, richer countries claim an ever escalating need for doctors, who migrate from poorer countries, with an ensuing global health workforce crisis. These political, social, demographic and international events necessitate a discussion on the roles and values of the doctor in the world today. The international mobility of both doctors and patients underlines the need for a global definition. Only when these roles and values are agreed in a global perspective, will medical education be capable of producing a professional equipped to fulfil that role. This doctor will then be useful both as a leader and as a member of health care teams with a flexible composition, related to resources and needs of particular regions, and at the same time be able to practise within any given health care system. An international task-force of the World Federation for Medical Education (WFME) is working to agree themes relevant to the role of the doctor globally, and developing a statement that can be used world-wide, and used to develop medical education policy.