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Name: Suzie Walker Student Number: n8104379 T utor's Name: Judith Meiklejohn

**It is estimated that 450 million people worldwide have a mental health problem**. (WHO, 2001).

= = == ** Cultural Artefact **



** Casa de Locos ** Casa de Locos (translated as The Madhouse) was painted by Francisco Goya in 1819. It is an oil on panel painting and depicts several unfortunates in various anguished poses devoid of personal dignity, not even afforded the basic provision of clothing. The figures are apparently locked inside an institution. The building is austere, without furniture and with only minimal natural light provided by a single high, barred window. The painting is regarded as a masterpiece and is housed in the Royal Academy of Fine Arts of San Fernando in Madrid, Spain.

= = ** Public Health Issue ** In modern times, the incidence of mental illness in Australia is lower when compared to the United Kingdom (UK) and America (USA). Officially 20% (AIHW, 2010, ABS, 2008) of our adult population have mental illness of any description in any 12 month period**.** In the UK, it’s 25% (MHF, 2011) and in America it’s 26% (NIMH, 2011) in any year. According to the World Health Organisation (WHO, 2011) combined male and female suicide rates compare as follows: in Australia: 16.4 people per 100,000 take their lives annually, in the UK: 13.9 and USA: 22.2. The highest rates were in The Russian Federation (63.4), Lithuania (71.7) and The Republic of Korea (62). The lowest rates were recorded in The Maldives, Antigua, Barbuda and Armenia.

= = ** Literature Review ** Mental illness has been around as a phenomenon for almost as long as we have had written records. There are examples of attempts at diagnosis by Hippocrates (460-377BC), Plato (427-347BC) and Aristotle (384-322BC). Throughout the ages, the treatment of mental illness has varied between care in the community (Roff, 1995) provided by families and social institutions such as churches, to care provided by large mental institutions. In England, the most infamous state run hospital is known as “Bedlam”, The Bethlem Royal Hospital. The hospital is still operational and has had continuous operation as a hospital for the mentally ill for 750 years (Whittaker, 2011). It’s current incarnation bears little resemblance to the hospital bearing it’s name in medieval times when tourists could pay to view the insane and their antics. Treatment consisted primarily of being manacled to the wall or floor (Whittaker, 2011). Australia, the United Kingdom and America have all followed Italy in the last thirty years by undertaking similar national policies that have favoured closure of traditional mental health institutions and the promotion of ‘care in the community’ (Sharp, 2004). Community care takes the form of acute psychiatric wards in general hospitals, outpatients clinics and residential, non-hospital facilities. Sharp, 2004, found that even in Italy, at the vanguard of radical mental health reform, the target of 100% deinstitutionalisation had not been possible. Official statistics had chosen not to reflect that some of the ‘closed’ mental hospitals still housed the chronically mentally ill, and that the country was unable to completely enforce public policy due to local government disagreement. Damningly, in Australia, the United Kingdom and America, only about a third of sufferers of mental illness actually receive care for their illness (MHCA, 2008, MHF, 2011, NIMH, 2011). This is true despite the fact that the Australian public health system including mental health services is accessible to everyone. Medicare Australia provides for about 70% of the cost of Mental Health Services (AIHW, 2010), whereas Medicare and it’s equivalent in the US provides for about 60% (NIMH, 2011) of the cost of Mental Health services and about 85% (NIMH, 2011) of the American population have private health insurance which constitutes a ‘user-pays’ system. The high cost of health care and associated debt have been cited in 62% of all bankruptcies that occurred in 2007 (NIMH, 2011). Links between unemployment and some mental illnesses have been strongly established especially those relating to the depressive spectrum. Comparative unemployment figures calculated by the US Bureau of Labour Statistcs (2011) indicated that in 2010 in Australia, 5.2% of the labour force was unemployed, in the UK, 7.9% were unemployed and in the US, 9.6% were unemployed. These figures are in keeping with the population statistics for mental illness and of particular concern in America where unemployment most probably means lack of access medical insurance and therefore to health services including mental health care. Health Spending in Australia appears to be more efficiently dispersed to provide the care available compared to the archaic systems in America and the UK. America appears to spend the highest in terms of GDP on health care (16%) with the worst outcomes. In 2002, $1.6 trillion was spent on health in the US (NIMH, 2011) Funds spent on the provision of mental health constituted about 6% of the health budget. In Australia, 2007-08 health expenditure constituted 9.1% of GDP and the mental health budget consisted of 3% of the $103.6 Billion health budget (AIHW, 2010). In the UK, during the same period, health expenditure constituted 8.4% of GDP (MHF, 2011). The high prevalence of mental illness amongst prisoners of the penal system here and in the UK and the USA would seem to indicate that in part, correctional institutions are undertaking part of the role of the dedicated mental institutions of the past. Incidence of mental illness amongst prisoners in the UK is estimated to be 70% (MHF, 2011), in America this figure is estimated to be 64% (NIMH, 2011) and in one study in NSW, up to 80% of women and 64% of men currently serving a sentence had a mental illness (Butler, 2009). Another minority group in society that is a big concern for national mental health is highlighted by the plight of the homeless. In Australia in 2003, 105,000 were estimated to be homeless, about 0.5% (ABS, 2011). Estimates of the incidence of mental illness in this group are as high as 85% (AIHW, 2010). In America, the number of homeless is estimated to be 1% of the population (NIMH, 2011), and the UK is acknowledged as having one of the highest rates of homelessness in Europe, an actual figure is hard to define because of the inherently difficult nature of calculating homelessness. It can be assumed however, that very few of these people have access to adequate mental health care measures as a direct result of their circumstances.

= = ** Cultural and Social Analysis ** Cristofalo et al, 2009 found that there were many barriers to effective mental health provision in community clinics in America. Some of these were: complex social problems such as homelessness, low or no income, absence of medical insurance, complex cultural characteristics including religion, language differences and social marginalisation, limited time to meet with clients, limited numbers of qualified psychiatric personnel, lack of integrated transport options to arrive at facilities, inability to treat contributing substance abuse issues, reduction in health funding for human services and social stigmatism. As Eisenhauer (2008) argues, social stigmatism relates to the fear of the ‘Other’, of the overthrow of the natural order by a force beyond your control. Secker et al, 2009 described the state of mental health care provision in the UK as having two main elements – care of individuals experiencing mild mental health issues such as anxiety and mental illness spectrum disorders, and care of those experiencing serious mental illness. Those in the first category are primarily attended to by general practitioners and community psychiatric nurses. Those of the latter category are directed toward specialised health resources. It would appear that community psychiatric nurses’ workloads are often over subscribed and underfunded. Case loads end up being shared by other nursing providers such as health visitors, school nurses and district nurses. Secker discusses the systems as being disorganised and poorly coordinated with little monitoring and ultimately care for the mentally ill being poorly provisioned. The concepts of individualism and self determinism that are prevalent in Western cultures are examples of what Eckersley and Dear (2002) described as risk factors for increased suicide. Emile Durkheim (1897, 1951) described the idea of egoism, as being relevant in societies where there is excessive emphasis on the individual and their needs as opposed to those of the community in which they live. He believed this had significance when considering suicide. As there is a high correlation between suicide and mental illness, these two paradigms can be considered together (MHF, 2011, NIMH, 2011). Care in the community implies a high degree of social integration of those suffering a mental illness to be effective as a model. This would appear to be in contrast to what is actually happening in practise. As only a third of sufferers of mental illness are actually seeking treatment, it follows that sufferers of mental illness aren’t connected to their community resources. ABS (2011) statistics have shown an increase in the incidence of suicide in Australia in the 1980’s and 90’s at the height of the implementation of care in the community, and reflecting the high degree of individualism experienced by those with a mental illness. Most compelling appears to be other less easily defined factors such as social mood and economic performance. The 7.30 Report (October 11, 2011) ran a story about the occupation of Wall St by protesters for a period of 3 weeks, reflecting the deep economic and social unrest evident in America in recent times. Joseph Reed, an unemployed man in a soup kitchen was interviewed and described the feeling of having no voice and a sense of powerlessness in the face of economic hardship. The internet, smart phones and instant global news coverage has meant this phenomenon is being described as a ‘movement’ as it has been transmitted globally in a very short space of time. In the UK, recent rioting in several major cities including the capital have reflected low societal confidence and again the use of technology has enabled rapid swarming of groups of disaffected protestors (BBC, 2011).

= = ** Analysis of the Artefact and Personal Learning Reflections ** Goya’s painting Casa de Locos is a disturbing painting depicting appalling conditions for the mentally ill. The painting challenges the viewer to see how their fellow man is treated once deemed insane and safely locked up in a mental institution. Institutionalisation was a common form of incarceration in most Western countries up until very recent times, and whilst conditions had improved by the end of last century, there had been a long history of neglect prior to that. Society preferred to provide a solution that in most aspects resembled penal incarceration to effectively isolate those afflicted with conditions that threaten the natural order. Social stigmatism is often exacerbated by exaggerated portrayals of mental illness especially in art over the ages. In more recent times, there have been public health campaigns that have aimed to reduce social stigmatism of mental illness. Care has been redirected from large state run institutions to specialised acute units in general hospitals and also community clinics. These measures haven’t necessarily had their desired outcomes with mental health provision overburdening community resources, increased suicide rates, and a minority of mental health sufferers not seeking treatment at all. Society favours individual goals which theoretically should assist individuals in taking responsibility for their mental health outcomes. This body of research had enabled me to see that unfortunately, due to the complexity of mental health issues, individualism is actually a determinant for poor mental health outcomes as individuals find it difficult to integrate to a fractured society displaying low confidence in existing social constructs during a period of unstable economic conditions. Governments here and abroad seemingly spend vast amounts of national funds on providing health care without apparently making much difference.

** Links ** Australia: [] []? United Kingdom [] [] USA [] []

= = ** References **
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