Review and Analysis of mental health reforms in several countries: Implementation, comparison and future challenges

The leading cause of health-related disabilities worldwide, are mental health disorders [1]. More than 25 percent of the world population will experience mental and behavioral disorders. Mental disorders know no boundaries and affect individuals in all societies. In 2001, the World Health Report directed its focus to the neglect that mental health services have endured for decades. Mental health is imperative to the welfare of individuals, cultures and countries [1].


Introduction
The leading cause of health-related disabilities worldwide, are mental health disorders [1]. More than 25 percent of the world population will experience mental and behavioral disorders. Mental disorders know no boundaries and affect individuals in all societies. In 2001, the World Health Report directed its focus to the neglect that mental health services have endured for decades. Mental health is imperative to the welfare of individuals, cultures and countries [1].
Over the past 30 years, several counties have launched mental health reforms with the goal of improving their mental health systems. The reform process in each country varies slightly, but most have focused on treating mental disorders within the primary care system, confi rming that psychotropic drugs are accessible; moving from mental health hospitals to facilities within the community supported by psychiatric beds in general hospitals and home care; promoting campaigns for public awareness to defeat stigma and bigotry; including communities, families and consumers in the process of making decisions in regard to services and policies; initiating national policies, legislation and programs; educating mental health providers, and connecting mental health with other social sectors [2]. This article presents mental health reforms that were conducted in different countries around the world, compares barriers, presents trends for the future and highlights what can be learned from them.
Specifi cally, we conducted a review to address the core The information collected was then divided into four main themes. We sorted countries according to themes based on similarities in their reasons for initiating mental health reforms and they processes they undertook.
Our inspiration for the fi rst two themes was derived from the WHO's Mental Health Atlas [3]. The following two themes were created based on important factors in our review of each country's mental health reform.
Each theme emphasizes different aspects of the reform. This enabled us to research and compare mental health reforms in different countries. The themes are: Legislation and regulations. M ental health legislation contributes to the protection of human and civil rights for those with mental health disorders and concerns itself with facilities that provide treatment, personnel, professional training and service structure. It is comprised of provisions for protecting individual patients, as well as compulsory admissions and restraint, when necessary, and discharge criteria, among others [3]. Examples of service structure include the number of clinics, type and number of professionals available in each clinic and which treatments will be available.
Mental health policies, plans and programs. Policies generate accountability by providing norms to assess performance. Many national mental health policies specifi cally promote deinstitutionalization, which requires individuals to receive care in the community [4].
Mental health policies determine the vision for how the mental health of the population will be treated in the future, describing the framework that will be implemented to manage mental disorders. A thorough mental health policy will include coordination of essential activities and services to ensure that individuals in need receive appropriate care. It will also be structured to prevent fragmentation and ineffi ciencies in the healthcare system [2].
Eliminating the custodial approach and stigma. In 2001, the World Health Report stated that custodial mental hospitals should be phased out. In their place would arise community care facilities supported by psychiatric beds in general hospitals. Such community-based services can provide earlier treatment, which will lead to better outcomes and quality of life than that provided by institutional care. It can also help lessen the stigma of treatment. The process of dealing with this health and human rights issue and instituting the process of closing large psychiatric hospitals is occurring worldwide [2].
Deinstitutionalization/priority on community care and networks of care. A major focus of national mental health policies concerns deinstitutionalization. The United Nations [5] and the WHO [2] have stated that mental health care should be moved to community-based treatment facilities.
Networks of community facilities, including mental health centers, psychiatric units in general hospitals, day centers and residential facilities) will increase access to services [2]. Implementing networks of community services, where most individuals with mental disorders can be treated, including those in low-and middle-income countries is an essential component of increased accessibility [6].
The literature on healthcare reform from 1990 to 2019 is vast. A historical review of each reform traces differences in the process that occurred in each country, some going back to the late 1970s. We created tables of results, summarizing data highlighting, key similarities and differences in each country. Some countries lack published information in articles and mental health atlases and for that reason not available (NA) appears in the tables.

Results
The attached tables present key elements comparing countries around the world regarding demographic information, healthcare professionals working in the mental health sector, policies, legislation and site of treatment.
T able 1 includes each country's demographic, economic, fi nancial information and type of healthcare system. Healthcare systems and mental health care funding vary.  Availability of mental health services varies according to income group in many countries. Those with high-incomes usually have better access, availability and options for specialized care, in comparison to patients in low-and middleincome countries. Care models differ accordingly, as well [7].
According to the WHO, every US dollar invested in improving treatment for common mental illnesses, such as depression and anxiety results in a return of $4 in better health and ability to work [8]. This should be considered when allocating funds for mental health care.
Mental disorders account for 13% of the global burden of disease, this number is expected to rise to almost 15% by 2030. Although the socioeconomic consequences are wellestablished, less than 1% of individuals in low-income countries with common mental disorders receive suffi cient care and only 10% in middle-income countries, such as China.
As many as 50% receive adequate care in most high-income countries [9].
As seen in Table 2, countries vary in the number of professionals working in the mental health sector. Provision of mental health care is based on the professionals in the fi eld. Their numbers need to increase and they need additional training to ensure suffi cient staff is available to provide specialized care and support the primary health care programs.
Numerous developing countries lack suffi cient numbers of these specialists to staff mental health services. Initial mental health care is best provided in the primary care setting, although specialists who can provide a broader range of services are lacking. A team of mental healthcare specialists would ideally include psychiatrists, psychologists, psychiatric nurses and social workers, and occupational therapists, who are able to collaborate to provide well-rounded care and help integrate patients in the community [2]. Moving to a primary healthcare base, requires staff who are trained in detecting and treating mental health disorders. Comprehensive training would require attention to primary health care workers who might be uncomfortable dealing with mental disorders. Thus, in addition to providing new skills, training should also encompass the potential reluctance of primary healthcare providers to work with individuals with mental health disorders [1].
Mental health legislation constitutes the legal provisions for protecting the basic human and civil rights of individuals with mental health disorders. Mental health legislation is the cornerstone of mental health reforms, planning policies and mental health programs [10]. As can be seen in Table 3, most countries have dedicated, stand-alone mental health legislation, and those who do not, address legal provisions concerning mental health care in other laws. The WHO [2] proposed a set of essential drugs for treating and managing mental and behavioral disorders. Most countries have a national therapeutic drug policy that provides mental health patients with pharmacological treatment [11].
The type of treatment facility in each country is affected by mental health policy, legislation, demographics, fi nancial abilities, work force and infrastructure. As seen in Table 4, some countries have been able to provide community sites for long-term residential care, where others provide care in psychiatric hospitals or psychiatric units in general hospitals.  The mental health plan includes timelines for implementing the plan, shifting services and resources from mental hospitals to community mental health facilities and integrating mental health services into primary care.

Discussion
This article presents mental health reforms that were conducted in different countries around the world. It compares barriers, presents trends for the future and highlights what can be learned from them.

Theme 1: Legislation and Regulations.
As seen in Table 3, most countries have established mental health legislation. Italy, a pioneering country in mental health legislation began its mental health reform in 1978. It used legislation to abolish the practice of custodial psychiatry [12]. Italy has an independent body that assesses how well mental health legislation complies with international human rights, regularly inspects facilities and regionally reports annually [3]. Like Italy, many countries, including Saudi Arabia, Israel and Japan use dedicated legislation and annual inspections of compliance with mental health legislation and facility inspections [3]. Brazil, Australia, Belgium, Germany, Greece, Russia and South Africa have dedicated, stand-alone laws for mental health legislation and a dedicated authority or independent body to assess mental health legislation compliance with international human rights, which provides random inspections of facilities and partial enforcement of mental health legislation [3]. The United States, Spain, Sweden and France do not have stand-alone mental health legislation. Mental health is covered in other laws and assessment of compliance to mental health legislation is irregular or nonexistent [3].

Theme 2:
Mental health policies, plans and programs. Most countries have initiated governmental policies regarding mental health care during the past 30 years. As seen in Table 3, the main components of these policies are advocacy, promotion, prevention, treatment and rehabilitation. Dedicated mental healthcare policies have been devised by most countries. The United States and Canada do not have stand-alone mental health policies; yet, it is categorically cited in the general health policies [13].
Countries participating in the WHO's Mental Health Atlas have similar mental health plans and programs in that they focus on timelines for implementing the report, allocating funds to implement at least half of the elements of the program, shifting services and resources from hospitals to the community facilities and integrating mental health services into primary care [13].
Several countries have highlighted different priorities in their national mental health plans. Australia's priority themes include promoting mental health, preventing mental illness, increasing the responsiveness of service, enhancing quality, nurturing research, innovation and sustainability [3].
The United Kingdom's National Mental Health Plan has three priorities: access to crisis resolution/home treatment teams, access to intensive treatment for the fi rst three years will be provided to patients with a fi rst episode if psychosis from early intervention teams, and patients with strong needs will have access to assertive outreach teams [3].
The Netherlands' fundamentals include demand-driven care, organized care that is effective and transparent, deinstitutionalization, additional development of mental healthcare at the local level and a logical professional organization [3].

Theme 3: Eliminating the custodial approach and stigma
A custodial approach perpetuates the stigma surrounding seeking treatment for mental health [2]. The current status of each country can be seen in Table 4    Saudi Arabia. Among traditional Arabs, there is a stigma toward seeking mental health services. Many Muslim Arabs think that only "crazy people" seek mental health services and consider them ineffective. In addition, pursuing mental health services may negatively impact future marital prospects, and may lead husbands to divorce their wives or take another wife. Men also tend to resist searching for mental health services because seeking help from a psychiatrist can be seen as weakening their masculinity and reducing their sense of being the head of the family and the protector. Over the last 30 years, major strides have been made in the fi eld of mental health. These can be seen in the number of psychiatric hospitals, which have increased nine-times, and psychiatrists tentimes. The numbers of psychiatric nurses, psychologists and social workers have increased as well. The establishment of community based mental health centers is well underway [16].
Israel. The mental health insurance reform was launched in July 2015, when responsibility for treating patients with mental illness was transferred from the government to the four nationally mandated health maintenance organizations. The previously existing pre-reform division between physical and mental health caused a signifi cant disparity in service availability, expensive private care and stigma [17]. Structural changes, do not address stigma, but may lower the impact. Therefore, psychiatric services were moved to new locations where they were less visible and more accessible [18]. A main goal of the mental health reform was to link physical health and mental health and by doing so reduce stigma.
Japan. Mental illness has evoked great stigma. In the 1950s, most patients did not receive any care and were mainly confi ned at home. In the 1960s, many private psychiatric hospitals were developed and hence, patients were treated in hospitals and not in the community. The initial process of mental health reform in Japan is focusing on reducing the average length of stay and creating community care facilities [19]. Deinstitutionalization is a crucial element of national mental health policies. The United Nations [5] and WHO [2] have both stated that mental healthcare should be moved from hospitals to community-based treatment centers.
In the United States, there has been an increase in the number of emergency room visits due to the limited access to mental health care [14]. The development of community mental health care in the US has not reached the point where all mental health patients have access to care. The US differs greatly from other mental health reforms since community services are lacking and most people cannot afford what is available due to the cost of private insurance plans [14]. Canada's mental health care has moved from hospitals to the community, supporting primary mental health care. The reform improved primary care services by creating adult primary care teams to increase access to mental health services [1]. Brazil is in the process of deinstitutionalizing and incorporating psychosocial care centers and therapeutic homes for long-term patients [20].
Australia, thirty years of deinstitutionalization has reduced the number and size of stand-alone psychiatric hospitals, which have been replaced by acute beds in general hospitals and an array of community-based services [21]. In the United Kingdom, deinstitutionalization has been accomplished by closure of large asylums and the development of community-based services. Yet, there are still diffi culties such as staff turnover, dissatisfaction of patients and caregivers with emergency services and social exclusion due to stigma [22]. In the Netherlands, mental health reform brought about deinstitutionalization and downsizing of psychiatric hospitals and introduced integration of ambulatory services, community mental health centers and sheltered housing [23]. Since the 1960s, Sweden has focused on closing large mental hospitals; yet, the establishment of alternative Citation: Cohen [27]. According to research conducted in Spain, there is a need to develop median community services and programs for rehabilitation and resettlement in society [26]. In contrast, France shifted from psychiatry to mental health by decentralizing the mental health policy. A number of steps helped establish community-based psychiatry, such as a change in the medical approach, in that psychiatrists work with other specialists [28]. Hospital-based care is still very important and is identifi ed with under development of community services and inadequate sheltered housing for the most disabled patients [29]. Pre-reform Germany had a 70% rate of compulsory admissions, with an average length of stay of almost a year. More than 80% of treatment took place in closed wards. Since the process of mental health reform, psychiatric hospitals have downsized 50% of their beds and one psychiatric hospital has been closed [15]. There has been a development of out-patient community integrated mental health care programmers and residential services as well as building of general hospital psychiatric units [30]. Italy is one of the pioneering countries for mental health reform. It is most well-known for the process of deinstitutionalization, when it passed legislation in 1978 banning psychiatric hospitals.
Today there are only forensic psychiatric hospitals in Italy. All psychiatric beds are in specialized wards in general hospitals [12]. In Greece, the deinstitutionalization portion of the mental health reform focused on reducing the average number of hospitalizations by 40%, deinstitutionalizing psychiatric patients with chronic conditions, reducing admissions to mental hospitals, refurbishing and reforming mental hospitals and training mental health professionals. The reforms aspect of community care promoted mental health in the community by creating decentralized community networks of preventive, specialized treatment, community interventions against the stigma, and rehabilitation services [31]. In Russia, psychiatric hospitals provide treatment. Psychiatric outpatient care is provided by a system of psychiatric care dispensaries. Russia believes that due to pharmacotherapy, psychotherapy and social support, the need for psychiatric beds will decrease.
Their goal is to slowly build general hospital psychiatric units [32]. In 1983, there were few beds to treat psychiatric patients in Saudi Arabia. Over time, the number of psychiatric hospital beds, general hospital psychiatric units and community health care centers have increased [16]. In South Africa, mental health services reforms include down-sizing psychiatric institutions and developing community-based services [33]. Israel has fewer psychiatric beds per capital in general hospitals compared to most developed countries. However, the trend, like other countries, is to allocate more beds in general hospitals. Consistent with international trends, psychiatric beds have been reduced in psychiatric hospitals. There has been an increase in community-based mental health services, as well as public mental health clinics and rehabilitation services involving hostels, independent housing, social clubs and others [17]. The belief in Japan is that implementing deinstitutionalization gradually will have the advantage of continuing to learn from the experience of other countries [4].

Limitations
This review had several limitations that need to be addressed. Several countries lack suffi cient publications in English; therefore, the bulk of data for those countries was This re view found that most mental health reforms began with the process of deinstitutionalization without fully taking into account infrastructure for community care, fi nancing and the number of health professionals working in the mental health sector.
Based on our fi ndings, a number of steps should be considered when initiating mental health reform.

1.
To enact change in the fi eld of mental health, legislation must be present or developed to ensure the provision of human rights. Governments must be part of the process to establish policies and to allocate funds for treatment facilities, personnel, professional training and service structure. Policies generate accountability in that they offer a standard against which government performance can be assessed.
2. An essential step is thinking about the countries' fi nancial abilities and budgetary constraints. When considering budgetary constraints, a country can set priorities, choose a model of care in relation to high-, middle-or low-income countries and establish which services will be provided.

3.
It is crucial to the overall well-being of patients with mental disorders to establish intermediate community services which facilitate rehabilitation and integration back into the community and by doing so minimize stigma.