Do not be afraid of seeing a psy! There is no health without mental health !
When you go to see a psychiatrist for the first time in your life, you tend to be a little “nervous” as no other profession has more stigmas than this one. What on earth is he/she going to tell you? Will they analyze your gestures, the way you talk? Will they read between the lines and discover your good and bad sides? … However, all my worries disappeared when I met Professor Mezzich, President of the World Psychiatric Association (WPA). He told me that the majority of cases treated are not people labelled as “crazy”, but ordinary people suffering from depression and anxiety.
What a relief! Professor Mezzich pointed out that this is a very interesting time for psychiatry and mental health as a number of recent developments in the social field in general are now pointing out that there is “no health without mental health”. He continued by saying that: “Our concept of health should be more comprehensive. It should not focus simply on physical symptoms or pathology, but also on psychological and social well-being.” The mental aspect of any illness is very important in becoming well again, as all health problems have a physical as well as a psychological and social side.
Do you think that the mental aspect of illness has been neglected?
Yes, the mental aspect of every illness has been neglected, to a large extent as a result of focusing almost exclusively on biological aspects, even by some groups within the psychiatric field. Some large groups emphasized the biological aspects of mental illness recently by paying a lot of attention to genetics, which I think opens up new perspectives. However, one should not overlook the social and psychological aspects of illness. The World Health Organization has recently established “a task-force on common ability”. This was because the specialists within the field of cardiology, for instance, said that when they were depressed patients did not recover from their heart problems—they did not listen to instructions, did not want to take the prescribed medicines, etc. Unless we look at the frequent coexistence of physical and mental disorders, treatment of one or the other is not as successful as it might be.
Q: So the role of the mental health is now increasing in all facets of the health services?
Well, it is emerging. For example, in this country (the United States) a specialty called psychosomatic medicine and psychiatry, paying attention to the border and interface between the physical and emotional or physiological aspects, is emerging in medical schools. There are a number of developments moving in this direction. For instance, last year there was a major ministerial conference, sponsored by WHO, on mental health in Helsinki (Finland). All the European Ministers of Health were present to address the issue of mental health in order to improve the well-being of their peoples. A very strong statement on this topic was issued by the Ministers, which once again emphasized the indispensability of mental health and the need to pay attention to the totality of the person in order to achieve general health. This is the other major perspective and concern that is emerging.
Q: It seems that people nowadays have “a better quality of life”, but at the same time I have never met so many “unhappy people”. How do you explain this?
I think that depression is a very prevalent condition. In fact, you can see that there are a number of unhappy people. There are many things in the world that are not going well and this provides the basis for unhappiness. There have been so many disasters in recent years and this has become a major activity for the World Psychiatric Association—disaster response. In addition to these general feelings of unhappiness, there are more serious clinical conditions of depression that are increasingly being recognized. Not only is it prevalent, but it is also frequently associated with a lot of disability—so much so that right now it has become one of the top two health conditions in terms of the burden of wellness of the population of the world, and affects both developed and developing countries. So clearly, depression is a major problem both clinically and in terms of the population’s concerns. The border between what is clinically pathological and what is just a general feeling of the population is not so precise, however.
For example, we have seen that many people do not have recognizable disorders that we could call depression according to the system of classification, but nevertheless they have quite a lot of disability associated with feelings of depression. We need to refine our classification system. One way to do this is to diagnose not only the illness, but to give a diagnosis of health—a diagnosis that looks at the presence of specific disorders, but also the positive aspects of health, such as functioning, social support and quality of life.
Q: There are many stigmas regarding your profession, such as “I do not need to go to see a psychiatrist as I am not crazy”. What do you think about a statement like that?
Well, I think this is a common feeling among many people. It also refers to the problems of stigmatization of the mentally ill, of psychiatrists and of psychiatry in general that you find in medical schools and in the community. There are efforts, including those of the WPA, to address this issue. One of the better ways of trying to decrease these stigmas that can increase people’s willingness to access to treatment and to make them happy is to recognize that all human beings should be the centre of attention, not the disorder they are suffering from. It could be said that even the most pathologically ill person is more healthy than ill, because there are many positive aspects in everybody’s functioning. Despite the fact that a person may have cancer, depression or any other kind of health problem, there are still many things that are still functioning normally in that person. Regardless of how ill you are, you might be able to have a quality of life that is basically a subjective phenomenon or perception of your own status of life and health that goes beyond some objective indicators of health. You might, for instance, see a meaning in your suffering, if you can appreciate your family or the small pleasures and joys of life—even if you are very ill.
Q: So if people are afraid of seeking help or going see a physiatrist, what would you say?
What you are pointing out is what a lot of people say: “Oh, I do not need to see a psychiatrist because I am not crazy.” It happens that most problems we see in our psychiatric services are not psychotic disorders. The majority of problems that we see—either in the in-patient or, increasingly, the out-patient community services—deal with stress, depression and anxiety-type disorders called affective disorders of various types. These are the vast majority of disorders; the psychotic disorders are only a small proportion. It is true that we now have a number of therapeutic instruments to help people with psychotic disorders, but even for depression and anxiety disorders we have biological, psychological and social tools to make people feel better. So it is a pity if somebody does not dare to see a psychiatrist because he or she is afraid of being labelled “crazy”. The vast majority of people, whatever the disorder, tend to get better with treatment. Even many people with psychotic disorders get better. Certainly, people with depression, anxiety disorders with sexual, obsessive conditions and even with personality disorders are increasingly able to get better, not only in terms of symptoms but also in functioning more effectively. This means being able to have a more productive and more enjoyable life.
Q: You were elected President of WPA. Why did you want to engage yourself in this association?
I was born in Peru and I studied medicine in Lima. The fact that my father was from Yugoslavia and my mother from Peru also increased my interest in international perspectives. However, I had never left Peru until I graduated from medical school. Then I came to the United States to do residency training and I continued working hard on research on many different aspects focusing on diagnosis, as I thought that this was the keystone of clinical care. I did my training at the University of Ohio, and started my medical career at Stanford University in California. I then moved to the University of Pittsburgh where I did many years of academic work.
In 1983, I crossed the Atlantic for the first time to attend the World Congress of Psychiatry meeting in Vienna. It was a turning point in my life. I was fascinated by coming into contact with psychiatrists from all over the world. We spoke different languages and had different approaches, but at the same time we had the same commitment: to try to help people with mental problems and grapple with the complexity of this subject. I was very fortunate to be appointed Secretary of the Committee on Classification. My area of research is diagnosis systems, so I was delighted to have the opportunity to work with all the specialists on diagnosis and classification. I worked there for many years and, eventually, I was given the chair of the Committee on Classification of the WPA, where I remained until 1996. I realized that, given its crucial importance in the field and in order to advance the perspectives on diagnosis, it would be a good idea to have a broader position within WPA, so I ran for Secretary-General. I was fortunate to be elected by the Assembly in Madrid in 1996. I organized the Secretariat here in New York city—that is the usual procedure, the Secretary-General organizes the Secretariat in the place where he or she is working. The Secretariat became a professional organization. We hired a lady from Russia to become head of the Secretariat and together we worked very closely to lay the basis for a modern and well-functioning Secretariat. It worked so well. Even after I finished my six-year period as Secretary-General in 2002, the Secretariat remained in New York for a few more years. Last year, after a careful search around the world, the Secretariat moved to Geneva. The authorities offered us very nice premises and good facilities. Thus, we have just entered a new period in the life of the Secretariat.
Q: Was this a strategic choice in order to be close to the World Health Organization?
That was one of the considerations, but not the only one. Certainly, being in proximity to the World Health Organization was an interesting factor, as we have always had a very close relationship to WHO and this relationship is now growing. For example, I paid a visit to the Director-General of WHO, Dr Lee, the Director of Non-Communicable Diseases and Mental Health and the Director of Mental Health. Dr Lee is very interested in mental health. He pointed out that without mental health all the diagnoses for infections are not well received and do not have the impact that they should. We have planned periodic joint statements with WHO on the situation of mental health around the world and recommendations for the future. Their recognition of WPA as the largest organization in the world in the field of psychiatry and mental health is certainly positive. We have 130 national psychiatric member societies around the world, and almost all countries are now represented. There are a few countries that are still getting organized. We do not yet have a member society in Cambodia, nor in Nepal.
For example, in Papa New Guinea we have an association consisting of a few members—only a handful—but they have had a psychiatric association for years. It is a very smart move, because they obtain support from the community of psychiatrists around the world. They receive educational programmes and contacts with other health professionals as well, establishing links with general practitioners, nurses, psychologists, social workers, etc. Thus, even in small countries we have member societies that are working increasingly with other health professionals.
Q: So you are putting mental health on the agenda everywhere?
Exactly. In addition to a World Congress every third year, we have international congresses every year. This year it will be held in Istanbul, which is the crossroads between Asian and European countries. Next year we will have one in Melbourne (Australia) where the theme is “Working together towards mental health”. So, we see our work as very challenging and interesting.
Q: What are your goals as President of WPA?
When I finished my six-year-term as Secretary-General, I was fortunate to be elected President-Elect. I just started my Presidency a couple of months ago and my presidential theme reflects the strategic plan that was approved by the WPA General Assembly in September 2005 in Cairo. It states that institutional consolidation and global impact towards psychiatry for the person are one of our main goals. This is in addition to advancing the identity of WPA and projecting ourselves onto the world community in collaboration with WHO. We can then analyze the problems of psychiatry and mental health in the world and to make proposals for improvement. This is now becoming a reality and we are increasing our contacts with other colleagues.
Last month, while at the WHO, I met the President of the World Federation of Neurology, which is the equivalent of WPA in the field of neurology. He was a very interesting person who immediately spoke about the importance of working together, rather than becoming involved in a collegial dispute about what is neurology and what is psychiatry—there exists an area of vagueness between these two fields. We are also in contact with the World Organization of Family Doctors—for example, they have a very interesting group to study classification and diagnosis. Instead of just trying to determine a disorder, they are looking at what people are complaining about and clarifying what the problems of these people are and how they can be helped. We would like to learn about some of their experiences so as to develop diagnosis systems for psychiatry. And also for other specialists who are increasingly attentive to all of the problems that people present … and not only the ones that are the main reason why people come to see us.
In fact, we know that everywhere in the world people with mental problems are seen first by a non-psychiatrist. The reason is simple: there are not enough psychiatrists and people do not know to whom to talk regarding problems such as sleeplessness, inability to function normally, etc., so they go to see their family doctor. We would probably be able to diagnosis them as having a depressive disorder. In many societies, depression expresses itself more in terms of somatic disorders than psychological ones. So people may complain about restlessness, loss of appetite and weight, feeling down, feeling indecisive… Therefore, it is very important for us in the health professions to work in close collaboration, so that we can deal with how people present these problems in a coordinated way.
Q: Geneva is the humanitarian capital of the world. What are you doing in this field?
In fact, we are proposing to move forward in the health field by articulating science and humanism. Professor Sharma from India once pointed out that science is essential for psychiatry, but humanism is the essence. I think this nicely formulated statement is the recognition that health professions are help-professions. We are not only dealing with people’s illnesses, but also helping them to fulfil their life projects. In order to do so, we need to know much more than understanding their illnesses. We certainly need to diagnosis them carefully and competently—but we need to know their background, their goals, their aspirations and where they would like to go, so that we can help them to reach their objectives as far as possible.
If the OCHA needs some psychiatric assistance for disaster victims, would WPA be able to help? I would certainly say that we can …
Editor’s note: Having spent far longer in Professor Mezzich’s office than initially foreseen, I realized that psychiatry and psychiatrists were perhaps not a such a bad thing after all, and that—despite the stigmas—perhaps mental health is something that we ought to think more about. Each one of us.
New York March 2006
What a relief! Professor Mezzich pointed out that this is a very interesting time for psychiatry and mental health as a number of recent developments in the social field in general are now pointing out that there is “no health without mental health”. He continued by saying that: “Our concept of health should be more comprehensive. It should not focus simply on physical symptoms or pathology, but also on psychological and social well-being.” The mental aspect of any illness is very important in becoming well again, as all health problems have a physical as well as a psychological and social side.
Do you think that the mental aspect of illness has been neglected?
Yes, the mental aspect of every illness has been neglected, to a large extent as a result of focusing almost exclusively on biological aspects, even by some groups within the psychiatric field. Some large groups emphasized the biological aspects of mental illness recently by paying a lot of attention to genetics, which I think opens up new perspectives. However, one should not overlook the social and psychological aspects of illness. The World Health Organization has recently established “a task-force on common ability”. This was because the specialists within the field of cardiology, for instance, said that when they were depressed patients did not recover from their heart problems—they did not listen to instructions, did not want to take the prescribed medicines, etc. Unless we look at the frequent coexistence of physical and mental disorders, treatment of one or the other is not as successful as it might be.
Q: So the role of the mental health is now increasing in all facets of the health services?
Well, it is emerging. For example, in this country (the United States) a specialty called psychosomatic medicine and psychiatry, paying attention to the border and interface between the physical and emotional or physiological aspects, is emerging in medical schools. There are a number of developments moving in this direction. For instance, last year there was a major ministerial conference, sponsored by WHO, on mental health in Helsinki (Finland). All the European Ministers of Health were present to address the issue of mental health in order to improve the well-being of their peoples. A very strong statement on this topic was issued by the Ministers, which once again emphasized the indispensability of mental health and the need to pay attention to the totality of the person in order to achieve general health. This is the other major perspective and concern that is emerging.
Q: It seems that people nowadays have “a better quality of life”, but at the same time I have never met so many “unhappy people”. How do you explain this?
I think that depression is a very prevalent condition. In fact, you can see that there are a number of unhappy people. There are many things in the world that are not going well and this provides the basis for unhappiness. There have been so many disasters in recent years and this has become a major activity for the World Psychiatric Association—disaster response. In addition to these general feelings of unhappiness, there are more serious clinical conditions of depression that are increasingly being recognized. Not only is it prevalent, but it is also frequently associated with a lot of disability—so much so that right now it has become one of the top two health conditions in terms of the burden of wellness of the population of the world, and affects both developed and developing countries. So clearly, depression is a major problem both clinically and in terms of the population’s concerns. The border between what is clinically pathological and what is just a general feeling of the population is not so precise, however.
For example, we have seen that many people do not have recognizable disorders that we could call depression according to the system of classification, but nevertheless they have quite a lot of disability associated with feelings of depression. We need to refine our classification system. One way to do this is to diagnose not only the illness, but to give a diagnosis of health—a diagnosis that looks at the presence of specific disorders, but also the positive aspects of health, such as functioning, social support and quality of life.
Q: There are many stigmas regarding your profession, such as “I do not need to go to see a psychiatrist as I am not crazy”. What do you think about a statement like that?
Well, I think this is a common feeling among many people. It also refers to the problems of stigmatization of the mentally ill, of psychiatrists and of psychiatry in general that you find in medical schools and in the community. There are efforts, including those of the WPA, to address this issue. One of the better ways of trying to decrease these stigmas that can increase people’s willingness to access to treatment and to make them happy is to recognize that all human beings should be the centre of attention, not the disorder they are suffering from. It could be said that even the most pathologically ill person is more healthy than ill, because there are many positive aspects in everybody’s functioning. Despite the fact that a person may have cancer, depression or any other kind of health problem, there are still many things that are still functioning normally in that person. Regardless of how ill you are, you might be able to have a quality of life that is basically a subjective phenomenon or perception of your own status of life and health that goes beyond some objective indicators of health. You might, for instance, see a meaning in your suffering, if you can appreciate your family or the small pleasures and joys of life—even if you are very ill.
Q: So if people are afraid of seeking help or going see a physiatrist, what would you say?
What you are pointing out is what a lot of people say: “Oh, I do not need to see a psychiatrist because I am not crazy.” It happens that most problems we see in our psychiatric services are not psychotic disorders. The majority of problems that we see—either in the in-patient or, increasingly, the out-patient community services—deal with stress, depression and anxiety-type disorders called affective disorders of various types. These are the vast majority of disorders; the psychotic disorders are only a small proportion. It is true that we now have a number of therapeutic instruments to help people with psychotic disorders, but even for depression and anxiety disorders we have biological, psychological and social tools to make people feel better. So it is a pity if somebody does not dare to see a psychiatrist because he or she is afraid of being labelled “crazy”. The vast majority of people, whatever the disorder, tend to get better with treatment. Even many people with psychotic disorders get better. Certainly, people with depression, anxiety disorders with sexual, obsessive conditions and even with personality disorders are increasingly able to get better, not only in terms of symptoms but also in functioning more effectively. This means being able to have a more productive and more enjoyable life.
Q: You were elected President of WPA. Why did you want to engage yourself in this association?
I was born in Peru and I studied medicine in Lima. The fact that my father was from Yugoslavia and my mother from Peru also increased my interest in international perspectives. However, I had never left Peru until I graduated from medical school. Then I came to the United States to do residency training and I continued working hard on research on many different aspects focusing on diagnosis, as I thought that this was the keystone of clinical care. I did my training at the University of Ohio, and started my medical career at Stanford University in California. I then moved to the University of Pittsburgh where I did many years of academic work.
In 1983, I crossed the Atlantic for the first time to attend the World Congress of Psychiatry meeting in Vienna. It was a turning point in my life. I was fascinated by coming into contact with psychiatrists from all over the world. We spoke different languages and had different approaches, but at the same time we had the same commitment: to try to help people with mental problems and grapple with the complexity of this subject. I was very fortunate to be appointed Secretary of the Committee on Classification. My area of research is diagnosis systems, so I was delighted to have the opportunity to work with all the specialists on diagnosis and classification. I worked there for many years and, eventually, I was given the chair of the Committee on Classification of the WPA, where I remained until 1996. I realized that, given its crucial importance in the field and in order to advance the perspectives on diagnosis, it would be a good idea to have a broader position within WPA, so I ran for Secretary-General. I was fortunate to be elected by the Assembly in Madrid in 1996. I organized the Secretariat here in New York city—that is the usual procedure, the Secretary-General organizes the Secretariat in the place where he or she is working. The Secretariat became a professional organization. We hired a lady from Russia to become head of the Secretariat and together we worked very closely to lay the basis for a modern and well-functioning Secretariat. It worked so well. Even after I finished my six-year period as Secretary-General in 2002, the Secretariat remained in New York for a few more years. Last year, after a careful search around the world, the Secretariat moved to Geneva. The authorities offered us very nice premises and good facilities. Thus, we have just entered a new period in the life of the Secretariat.
Q: Was this a strategic choice in order to be close to the World Health Organization?
That was one of the considerations, but not the only one. Certainly, being in proximity to the World Health Organization was an interesting factor, as we have always had a very close relationship to WHO and this relationship is now growing. For example, I paid a visit to the Director-General of WHO, Dr Lee, the Director of Non-Communicable Diseases and Mental Health and the Director of Mental Health. Dr Lee is very interested in mental health. He pointed out that without mental health all the diagnoses for infections are not well received and do not have the impact that they should. We have planned periodic joint statements with WHO on the situation of mental health around the world and recommendations for the future. Their recognition of WPA as the largest organization in the world in the field of psychiatry and mental health is certainly positive. We have 130 national psychiatric member societies around the world, and almost all countries are now represented. There are a few countries that are still getting organized. We do not yet have a member society in Cambodia, nor in Nepal.
For example, in Papa New Guinea we have an association consisting of a few members—only a handful—but they have had a psychiatric association for years. It is a very smart move, because they obtain support from the community of psychiatrists around the world. They receive educational programmes and contacts with other health professionals as well, establishing links with general practitioners, nurses, psychologists, social workers, etc. Thus, even in small countries we have member societies that are working increasingly with other health professionals.
Q: So you are putting mental health on the agenda everywhere?
Exactly. In addition to a World Congress every third year, we have international congresses every year. This year it will be held in Istanbul, which is the crossroads between Asian and European countries. Next year we will have one in Melbourne (Australia) where the theme is “Working together towards mental health”. So, we see our work as very challenging and interesting.
Q: What are your goals as President of WPA?
When I finished my six-year-term as Secretary-General, I was fortunate to be elected President-Elect. I just started my Presidency a couple of months ago and my presidential theme reflects the strategic plan that was approved by the WPA General Assembly in September 2005 in Cairo. It states that institutional consolidation and global impact towards psychiatry for the person are one of our main goals. This is in addition to advancing the identity of WPA and projecting ourselves onto the world community in collaboration with WHO. We can then analyze the problems of psychiatry and mental health in the world and to make proposals for improvement. This is now becoming a reality and we are increasing our contacts with other colleagues.
Last month, while at the WHO, I met the President of the World Federation of Neurology, which is the equivalent of WPA in the field of neurology. He was a very interesting person who immediately spoke about the importance of working together, rather than becoming involved in a collegial dispute about what is neurology and what is psychiatry—there exists an area of vagueness between these two fields. We are also in contact with the World Organization of Family Doctors—for example, they have a very interesting group to study classification and diagnosis. Instead of just trying to determine a disorder, they are looking at what people are complaining about and clarifying what the problems of these people are and how they can be helped. We would like to learn about some of their experiences so as to develop diagnosis systems for psychiatry. And also for other specialists who are increasingly attentive to all of the problems that people present … and not only the ones that are the main reason why people come to see us.
In fact, we know that everywhere in the world people with mental problems are seen first by a non-psychiatrist. The reason is simple: there are not enough psychiatrists and people do not know to whom to talk regarding problems such as sleeplessness, inability to function normally, etc., so they go to see their family doctor. We would probably be able to diagnosis them as having a depressive disorder. In many societies, depression expresses itself more in terms of somatic disorders than psychological ones. So people may complain about restlessness, loss of appetite and weight, feeling down, feeling indecisive… Therefore, it is very important for us in the health professions to work in close collaboration, so that we can deal with how people present these problems in a coordinated way.
Q: Geneva is the humanitarian capital of the world. What are you doing in this field?
In fact, we are proposing to move forward in the health field by articulating science and humanism. Professor Sharma from India once pointed out that science is essential for psychiatry, but humanism is the essence. I think this nicely formulated statement is the recognition that health professions are help-professions. We are not only dealing with people’s illnesses, but also helping them to fulfil their life projects. In order to do so, we need to know much more than understanding their illnesses. We certainly need to diagnosis them carefully and competently—but we need to know their background, their goals, their aspirations and where they would like to go, so that we can help them to reach their objectives as far as possible.
If the OCHA needs some psychiatric assistance for disaster victims, would WPA be able to help? I would certainly say that we can …
Editor’s note: Having spent far longer in Professor Mezzich’s office than initially foreseen, I realized that psychiatry and psychiatrists were perhaps not a such a bad thing after all, and that—despite the stigmas—perhaps mental health is something that we ought to think more about. Each one of us.
New York March 2006
