SCHIZOPHRENIA

 

 

 

 

AND

 

 

 

 

THE AFRO-CARIBBEAN COMMUNITY

IN THE UNITED KINGDOM

 

 

 

ABSTRACT

Schizophrenia is a major mental disorder where a person experiences delusion and abnormality in thinking (Alexander, 2008; Mueser and McGurk, 2004). In the last 20 years, the disease has been highly diagnosed in the Afro-Caribbean community leading to certain factors being linked to the cause (Bhugra et al., 1999). This community has been highly diagnosed with schizophrenia due to effects of inequalities within health services such as racism, discrimination, poverty and poor health (Department of Health, 2011). Further, evidence suggests that genetic basis of inheritance, and social factors such as childhood traumas are likely to result to schizophrenia (Murray et al., 2009). In addition, the community is highly prone to drug abuse such as cannabis and other social misfits. These factors may also increase their proneness to the disease (Fernando, 2012). However, very little connection has proved this as schizophrenia also affects non-users of cannabis (Hickman et al., 2009; Hubbard and Martin, 2005). Likewise, it is a global illness that not only differs in various ways and cultures, but is all over the world (Bhugra, 2005).

 

 

 

 

 

 

 

 

 

TABLE OF CONTENTS

Abstract………………………………………………………………………………………………………………….2

Contents Page………………………………………………………………………………………………3

1.1 Introduction………………………………………………………………………………………………4

2.1. Aims and Objective…………………………………………………………………………………..5

2.2. Background ………………………………………………………………………………………6 & 7

3.1 Methodology…………………………………………………………………………………………….7

3.2 Scope………………………………………………………………………………………………………7

4.0 Discussion of findings ……………………………………………………………………………….8

4.1 Characteristics of a person suffering from Schizophrenia……………………………….8

4.2 Relationship between schizophrenia and afro-Caribbean…………………………..8&9

4.3 Racism and mental Health……………………………………………………………8, 9, 10, 11

5.0 A review of mental health policy in the UK from anti-racist perspective……..11&12

6.0 Conclusion……………………………………………………………………………………………..13

7.0 Recommendations…………………………………………………………………………………..14

8.0 References………………………………………………………………….15,16,16,18,19,20,21

9.0 Appendix………………………………………………………………………………………………..22

 

 

1.1 INTRODUCTION

The world Health Organization( WHO, 2001) ental health and particularly schizophrenic patients is on the rise.

The Afro-Caribbean community, a community originating mainly from the Caribbean islands (Callan, 1996), has been highly diagnosed with schizophrenia from earlier studies relating to ethnicity and health (Cantor & Centor, 2005; Sugarman & Crauford, 1994). The community has been the centre of study in relation to schizophrenia and psychotic conditions as the incidence has been high in the last 20 years (Arai and Harding, 2004). , 2009). The problem mainly arises from effects of wider racism against the blacks (Sheppard, 1999). This can be through such experiences like growing up in a hostile environment with fewer positive and many negative images against these individuals (Sheppard, 1999; Hutchinson &Hassen, 2004). Such factors include unemployment and nature of education among others (Bhugra et al., 1999). In addition, institutionalized racism (McKenzie and Bhui, 2007) has affected many black people who access mental health treatment in the manner the psychiatrists treat their condition with complaints that there is a general bias that blacks are more affected by the disease (Keating, 2007). This has continued to raise tensions and distrust on both sides (Keating et al., 2002; Fernando, 2012)

 

 

 

2.1 Aims and Objectives

 

The aim of this report is to critically analyze research literature regarding schizophrenia and other related illness that affect the Black ethnic minority. It will focus mainly on the Afro-Caribbean’s.

 

• The objective of this report will look atin relation to black Afro-Caribbean in Britain.
• To analyze relevant policy regarding schizophrenia and mental health illnesses from an anti-racist perspective.
• To give recommendation of how best peoples’ perception towards schizophrenia can be improved as well as services.

 

 

 

 

 

 

 

 

 

 

2.2 Background

 

An ethnic community normally is classified as sharing the same origins or common background, have a shared culture or tradition and have a common language or religious traditions (Agyemang, 2005). The Afro-Caribbean’s in Europe came mainly from the colonies and from West Indies in the 1950s, and 1960s (CruikShanks & Beevers, 1989) and also consist about 80% of the total ethnic community in the UK (Keating, 2007).

 

Studies have shown increased risk of schizophrenia in Afro-Caribbean’s in Britain (Sugarman & Crauford,1994) and statistics evidence has revealed over-presentation in prison population and mental health services due to misdiagnosis by doctors (Mason et al. 2012; Keating et al., 2002). An audit report by Commission for healthcare and inspection 2007, 2005 found that black and mixed race individuals were more likely to be hospitalized in psychiatric wards than the white people (Callan, 1996). What is disturbing is the contradicting information touching the police and the criminal justice taking advantage of part 111 of Mental Health Act, which allows them to detain someone ensuing to young black and particularly Afro-Caribbean males being detained and locked in mental units (Sheppard, 2002). Worse still, failures to understand the culture of the black people and particularly the Afro-Caribbean men by the British doctors have ended up with a wrong diagnosis hence a huge number also ending in mental units (charkraborty and Mckenzie, 2002. Such misfortunes have led to lack of faith with the mental health unit and has createdparticularly the Afro-Caribbean, who despite the high number of schizophrenia, do not access the primary care or dedicated community services (Keating and Robertson, 2004).

 

 

3.1 Methodology

 

A number of sites were searched, and a list websitesdata from the mentioned sources. Journal articles were obtained by cross search within the University e-Library and Discovery. Terms like Schizophrenia were used to search data. Also, using socINDEX, CINAHL and ‘PsycINFO’ databases gave a lot of quality results and the process was easier.

 

3.2 Scope

 

The report will focus mainly in United Kingdom but will also consider other research. Research databases will be searched for publications from 1994 through to present, even though search terms will remain broad

 

 

 

4.0 Discussion/Findings

4.1 Characteristics of a person suffering from schizophrenia

Schizophrenia is a disorder of thought and how a person perceives things, his/her mood, and behaviour as compared to a normal person (NICE 2013). These individuals suffer from paranoid delusions as disturbances of thought and change of behaviour different from consensus reality (Pringle, 2013). They experience hallucinationsthey are real, though they are not, and their reactions emotionally to events happening in their life is blunted (NHS Choices, 2012). The disease can occur in childhood or late adolescents, and has also been reported to occur i during pregnancy (Hall, 1988). In the United Kingdom, about 0.7% of children between the ages of 5-18 have psychotic disorders and most affected are those from the black race (NICE 2013).

 

4.2 Relationship between schizophrenia and afro-Caribbean population

 

The question of the relationship between schizophrenia and the Afro-Caribbean inhabitants has been the centre of study with many people trying to answer why these people are much more affected than their white counterparts (Pinto et al., 2008). Studies have showed certain factors such as perceptions by the British society towards the ethnic minority (Pote et al., 2002). Many authors have also suggested a list of factors that are racist-related that contribute to the prevalence. These include the high rates of unemployment (Peckham & Muller, 1999), poor housing; poor health and the students have a low record of academic achievement, high exclusion from schools (Keating 2007). A larger survey done titled “Aetiology and ethnicity in schizophrenia and other psychoses

 

 

4.3 Racism and Mental Health

 

Black people experience undesirable and discriminatory life events that can expose them to increased mental health issues (Karlsen, 2007). This group has a lot of disadvantages and discrimination that lead to future generations suffering even much more from the disease (Sheppard, 2002).For instance, research and statistical evidence indicate that Afro Caribbean and black men are more likely to be admitted to psychiatric wards than the white population (Commission for healthcare audit and inspection, 2005, 2007; Callan, 1996)

 

Further research has shown that more black and ethnic minorities are forcefully detained (Barnes et al., 1990) than the whites under section 136 of the mental Health Act (1983) (Fernando, 2003). They are locked up in secure units suspected to be dangerous criminals (Fernando, 2003; Sheppard 2002). This can be argued as racism. The number of black people forcefully put in mental health institutions went up since the introduction of Mental Health Act (2007) (BHM UK, 2013). It is a fact that racism and stereotypes (Sheppard, 2002). Clearly, their life expectancy is reduced greatly from lack of equal opportunities and absence of social inequality and distribution of resources (Sheppard, 2002) hence the challenge.

 

Some of the reported causes are genetic predisposition (Opler, 2013) is affected is likely to contribute to others getting it (Pinto et al. 2008; Dadic-Hero et al., 2013). This is a problem of the emigrated rather than the natives. These genetic factors act on the second generation (Fearon & Morgan 2006). However, it is also reported that studies done in the countries of origin showed that the prevalence of the disease in the mother countries was significantly lower (Fearon & Morgan 2006).

 

The second possible cause is selective migration. The ones mostly affected are those whose first generation parents already suffered the same (Hutchinson & Haasen, 2004). That is a problem showing that their parents were already exposed. Other factors include misdiagnosis, selective diagnosis by health practitioners with an assumption that blacks are usually highly likely to suffer from the disease (Chakraborty and McKenzie, 2002).

 

There is also a problem of the health services sector where treatment is affected since most people suffering don’t voluntarily go for treatment and only do so under coercion (Pinto et al. 2008). Socio-economicfactors like population settlement is also a contributing factor (Opler et al., (2013). (Boydell et al. 2001). Institutionalized and individual level of racism is a factor to blame(Sheppard, 2002).Racism directed at a person and racism coming from institutions offering services like employment or health services is also to blame for the problem that these individuals suffer (Thomas, 1998). Institutional racism has seen a lot of black patients being detained (Bhui, 2007)

 

The black males find themselves in situations that increase their vulnerability. Examples are drug abuse which is high in this community (Day & Norman, 2007). The effect of drug use leads schizophrenia and its effects like psychiatric problems (Cheung et al., (2010). They are excluded from schools or may not attend certain schools due to their origin; social deprivation and crime are also factors that have been attributed to be the cause

 

5.0 A review of mental health policy in the UK

The government of UK has made tremendous progress to tackle this problem and is aware of existence and challenges that these individuals go through to cope with schizophrenia (Crawford et al., 2003).

 

Department of Health (2011) came up with 6 strategy objectives to deal with the issues of mental illness in the areas of attitudes and services (DOH, 2011). They included handling the issue from the individual and institutional level where the sick get the services like employment, education, health and any other institutions that directly deals with or affects the prevalence of the disease.

 

 

Department of Health and Home Office, 2013 policy paper has emphasised the need for people to have. Some of the policies are drafted to deal with unemployment, health and tackling of gang culture, drugs and all other factors that are believed to increase the hazard (DOH, 2013). ( The New NHS, 2013)

 

rt in the next three years (DOH, 2014).

 

 

 

 

6.0 CONCLUSION

It is clear that issues like discrimination, racial inequality, lack of equal opportunities, poor health and education, expulsion from schools as compared to the whites has been known to contribute to the prevalence of the disease. Policies and particularly, the Mental Health Act (2007) appears to be oppressive and discriminatory against the blacks and other ethnic minority groups. The report has established that mental illness identified as schizophrenia is on the rise among the Afro-Caribbean population. It has also recognized not only the Afro-Caribbean population are affected but a wide range of people from different backgrounds. The afro-Caribbean community is the most affected ethnic community and requires adequate, and careful follow-up if their mental and physical health is to be addressed. There is over presentation of blacks and especially the Afro-Caribbean males. A basic and fundamental human right is a right to health care and they should not continue to face discrimination in the 21^st century especially in a developed nation. The making of policies is an important step by the government and implementation must follow suit.

 

 

7.0 Recommendations

Some of the suggestions for future are:

• Have the policies that the government is making implemented and enforced especially where criminal justice is involved.

 

• There must be a change of attitude against racism at individual and institutional level and institutions should be able to encourage the minority

 

• Ethnic communities to enjoy services given by them by intentionally having policies favouring them e.g. in employment.

 

 

• Schizophrenia can be dealt with, just like many other diseases in the past.

 

• The doctors and professionals within mental health services should be well informed of cultural differences and more doctors from ethnic minority groups who understand the background of this individual to be fully involved.

 

Word count: 2,196

 

 

References

 

Agyemang, C., Bhopal. R., & Bruijzeds, M. 2005. “Negro, Black, Black African, African-Caribbean, African-American or What? Labelling the African Origin Populations in the Health Arena in the 21^st century”. Journal of Epidemiology and Community Health, Vol 59.

Understanding schizophreniahttp://0-eds.b.ebscohost.com.brum.beds.ac.uk (Accessed 17 February 2014)

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1140960/ (Accessed 27 February 2014)

Bhui, K. (2002). ‘Racism and Mental Health: London’. Jessica Kingsley

British Medical Journal, Vol, http://0-ehis.ebscohost.com.brum.beds.ac.uk (Accessed: 15 March 2014)

 

Bhui, K. & Bhugra, B. (2002) ‘Mental illness in Black and Asian ethnic minorities: pathways to care and outcomes’ Advances in Psychiatric Treatment, http://0-ehis.ebscohost.com.brum.beds.ac.uk

 

 

Schizophrenia in Afro-Caribbean Immigrants ‘ Journal of the Royal society of Medicine, Department of Psychological Medicine, Vol. 89 (5) pp. 253-256. [Online] MEDLINE with Full Text, EBSCOhost. Available at: [Online] Available at:http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 12 February 2014)

Cantor-Graae., E, Selten, J. P. 2005. Schizophrenia and migration: a meta-analysis and review. American Journal of Psychiatry vol.162, pp.12–24.

Cantor-Graae, E. & Selten, P.J. (2005) Schizophrenia and migration: A Meta-Analysis and Review, Online American Journal of Psychiatry, 162(1) [Online]. Available at: http://journals.psychiatryonline.org/ (Accessed 15 March 2014)

Chakraborty, A. and McKenzie, K. (2002) ‘Does racial discrimination cause mental illnesses?’ British Journal of Psychiatry, 180 (6) pp. 475-477 Science citation Index with Full text, Ebscohost EJS [Online] Available at: http://0-ehis.ebscohost.com.brum.beds.ac.uk(Accessed: 22 February 2013)

Commission for Healthcare audit and inspection (2005) Commission for Healthcare audit and inspection Account 2004-2005, London: The Stationery Office [Online] Available at: http://www.official-documents.gov.uk/document/hc0506/hc03/0373/0373.pdf (Accessed: 10 March, 2014)

Commission for Healthcare audit and inspection (2007) State of healthcare 2007: Improvements and Challenges in service in England and Wales, London: Stationery Office [Online] Available at: http://www.official-documents.gov.uk/document/hc0708/hc00/0097/0097.pdf (Accessed: 10 March, 2014)

 

Cheung, J. Mann, R., Ialomiteanu, A. Stoduto, G. Chan, V,Ala-Leppilampi, K, & Rehm, J. (2010) ‘Anxiety and Mood Disorders and the Cannabis Use; American Journal ofDrug & Alcohol Abuse. Vol. 36 (2) pp. 118-122 [Online] SocINDEX with Full Text. Available at: http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 10 March 2014)

Crawford, V., Crome, I. & Clancy, C. (2003)’Co-existing problems of mental Health and Substance Misuse (Dual Diagnosis): The literature review; Drugs: Education, Prevention & Policy. Vol. 10 (1) [Online] SocINDEX with Full Text EBSCOhost Available at: http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 10/3/2014)

Cruickshanks JK, Beevers DG 1989. (eds). Ethnic Factors in Health and Disease. London: Butterworths.

Dadic-Hero, E, Ruzic, K, Palijan, T. Graovac, M, Siuc-Valkovic. D, Knez, R, & Grahovac, T. (2013), ‘Relations between the course of a illness, Family History of Schizophrenia and the Family Functioning in persons with Schizophrenia; Collegiums’ Antropologicum, Vol.37 (1) pp. 47-55, SoINDEX With Full Text, EBSCOhost [Online] Available at: http://0-eds.b.ebscohost.com.brum.beds.ac.uk (Accessed 8 March 2014)

Day, M. and Norman, R.L. (2007) ‘An Exploration of the gender differences in the initiation of and attitudes towards crack cocaine use in the English-speaking Caribbean’. Addiction Research & Theory 15 (3) pp. 285-297 [Online] Available at: http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 10 March 2012)

Department of Health (2011) ‘NO HEALTH WITHOUT MENTAL HEALTH: A cross-Government mental health outcomes strategy for the people of all ages. Analyses of the impact of Equality (EIE) [Online] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213763/dh_123989.pdf (Accessed 10 March 2014)

Department of Health (2014) ‘Mental Health: priorities for change: Making mental health services more effective and accessible. [Online) Available at: https://www.gov.uk/government/publications/mental-health-priorities-for-change(Accessed 10 March 2014)

Department of Health, and Home Office (2013) ‘Reducing drug misuse and dependency’. [Online] Available at: https://www.gov.uk/government/policies/reducing-drugs-misuse-and-dependence (Accessed 11 March 2014)

Elam, G., McMunn, A., Nazroo, J,. Feasibility study for Health Survey among black African people living in England. Final report for the Department of Health. London: Joint Health Surveys Unit and the National Centre for Social Research, Available from http://www.doh.gov.uk/pdfs/healthrptfeasibafricansurvey.pdf (accessed February 17 2014).

 

Fernando, S. (2012) ‘Race and the culture issues in mental health and some thoughts on the ethnic identity’. http://0-ehis.ebscohost.com.brum.beds.ac.uk (Accessed: 5 March 2014)

Cultural Diversity, Mental Health and Psychiatry: The Struggle Against Racism, East Sussex: Brunner- Routledge, G [Online] Available at: http://books.google.co.uk/books? (Accessed: 5 March 2014)

 

Gilvarry, C. M., Walsh, E, Samele, C, Hutchinson, G, Mallet, R, Rabe-Hesket, S, Fahy, ,, van Os, J. and Murray, RM 1999, Life events, ethnicity and perceptions of discrimination in patients with severe mental illness’, Social Psychiatry and Psychiatric Epidemiology, vol. 34, no. 11, pp. 600–608.

Schizophrenia [Online] Available at: http://www.nhs.uk/conditions/schizophrenia/Pages/Introduction.aspx

(Accessed: 5 March, 2013)

 

Great Britain. Department of Health (2014) Closing the gap: Priorities for essential change in mental health [Online]. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_V2_-_17_Feb_2014.pdf (Accessed 16 February 2014)

 

Habbard, J.R. and Martin, P.R. (eds.) (2005) Substance abuse in the mentally and physicallydisabled [Online] Available at: http://books.google.co.uk/books (Accessed 6 March 2014)

Addiction, 102, 4, pp. 597-606, SPORT Discus with Full Text, EBSCOhost, Available at:http://0-eds.a.ebscohost.com.brum.beds.ac.uk ( Accessed 6 March 2014)

Addiction, 104, 11, pp. 1856-1861, [Online] CINAHL Plus with Full Text, EBSCOhos. Available at: http://0-eds.a.ebscohost.com.brum.beds.ac.uk/ (Accessed on 6 March 2014

Karlsen, S., 2007. Ethnic Inequalities in Health: The impact of racism, Better Health Briefing 3, London: Race Equality Foundation.

 

Keating, F. 2007. African and Caribbean men and mental health: A race Equality Foundation Briefing Paper: [Online]. Available at: http://nmhdu.org.uk/silo/files/african-and-caribbean-men-mental-health.pdf (Accessed 15 March 2014)

Lewin, M (2009) ‘Schizophrenia epidemic among African Caribbeans spur Prevention Policy Change: Research shifts government mental health strategy to focus on ethnic minorities and controversial social issues [Online]. Available at: http://www.theguardian.com/society/2009/dec/09/african-caribbean-schizophrenia-policy(Accessed 15 March 2014)

Morgan, C. Dazzan, P. Fearon, P. (2006) ‘First episode and ethnicity: Initial findings from the AESOP study: World psychiatry Association.vol. 5(1) pp. 40-46. [Online] Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472260 (Accessed 27 February 2014)

Mason, O. Medford, S. and peters, E. (2012) ‘Ethnicity, violent offending, and vulnerability to schizophrenia: A pilot study; Psychology and Psychotherapy 85(2) pp.143-149, MEDLINE with Full Text, EBSCOhost http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 12 February 2014)

Mueser and McGurk (2004) ‘Schizophrenia’ Lancet, Vol. 363 (9426) pp 2063-2072. [Online] MEDLINE With Full Text, EBSCOhost. Available at: http://0-eds.b.ebscohost.com.brum.beds.ac.uk (Accessed 17 February 2014)

Murray.R.M., Di Forti, M and Howes, D. (2009) ‘Integrating the epidemiology and the pathogenesis of schizophrenia from the street to the striatum; Integrating the epidemiology and pathogenesis of schizophrenia’ in Gattaz, W.F. and Busatto, G. (eds.) Advances in schizophrenia research 2009 [Online] Available at: http://books.google.co.uk (Accessed 12 March 2014)

National Institute for Health and Care Excellence (NICE) (2013) Psychosis and schizophrenia in children and young people: Recognition and management, Available at: http://www.nice.org.uk/nicemedia/live/14021/62389/62389.pdf (Accessed 17th February 2014).

National Institute for Health and Clinical Excellence (NICE) (2010) Schizophrenia Core Intervention in the treatment and management of schizophrenia in adults in primary and secondary care (updated edition), London: The British Psychological Society and The Royal College of psychiatrists. [Online] Available at: http://www.nhs.org.uk/nicemedia/pdf/CG82FullGuideline.pdf (Accessed 17 February 2014)

Peckham, J. & Muller, J. (1999) ‘Employment and Schizophrenia: Recommendations to improve employability for individuals with schizophrenia’ Psychiatric Rehabilitation Journal, Vol. 22 (4) pp. 399. [ONLINE] EBSCOhost Available at: http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 10/3/14)

Pinto R, Ashworth M, & Jones R 2008, Schizophrenia in black Caribbean’s living in the UK: An exploration of underlying causes of the high incidence rate, the British journal of general practice vol. 58, no. 551, pp. 429-434.

Pinto, R., Ashworth, M., Jones, R., (2008) ‘Schizophrenia in black Caribbean’s living in the UK: An exploration of underlying causes of the high incidence rate’ British Journal of General Practice 58 (551) pp. 429-434. [Online] Science citation Index, Available at:http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 7 March 2014)

Pote, L. H. & Orrel W. M. (2002) ‘Perceptions of Schizophrenia in Multi-Cultural Britain’ Ethnicity & Health 7 (1) pp, 7-20 [Online] SoINDEX with Full Text, EBSCOhost, Available at:http://0-eds.b.ebscohost.com.brum.beds.ac.uk (Accessed 14 March 2014)

Pringle, R (2013), ‘Psychosis and schizophrenia: a mental health nurse’s perspective’, Nurse Prescribing, 11, 10, pp. 505-509, CINAHL Plus with Full Text, EBSCOhost, http://0-eds.a.ebscohost.com.brum.beds.ac.uk/ (Accessed on 6 March 2014)

Sheppard, M (2002), ‘Mental Health and Social Justice: Gender, Race and Psychological Consequences of Unfairness’, British Journal of Social Work’, Vol. 32, (6), pp. 779, SocINDEX with Full Text, EBSCOhost [Online] Available at: http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 10 March 2014)

 

Sugarman A. P. & Crauford (1994) ‘Schizophrenia in the Afro-Caribbean community’ The British journal of psychiatry. 164 pp. 474-480. [Online] Available at: http://bjp.rcpsych.org(Accessed 12/3/14)

The Health and Social Care Act (2013) ‘Engaging with BME Communities; Insight for Impact’ [Online] Available at: http://www.nhsconfed.org/Publications/Documents/Engaging-BME-communities-insights-for-impact.pdf (Accessed 11 March 2014)

Thomas. J.M (1998) ‘who feels it knows: Work Attitudes and excess non-white unemployment in the UK; Ethnic & Racial Studies, Vol. 21 (1) pp. 138-150 [Online] EBSCOhost , Available at: http://0-eds.a.ebscohost.com.brum.beds.ac.uk (Accessed 10/3/14)

World Health Organization (WHO) 2001, Mental Health: Strengthening mental healthpromotion, Factsheet No. 220 [Online]. Available at: http://www.who.int/whr/2001/en/(Accessed February 17 2014).