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This chapter gives an overview of the wide range in capacity and availability of mental health services around the globe. The first section discusses the concepts, definitions, measurement instruments, and sources of data bearing on global mental health and mental illness. That information provides background for the balance of the discussion by exposing the dearth of system-level instruments and readily comparable global data to help guide international public mental health policy. This is followed by an exploration of selected data on mental health systems around the world. Finally, the chapter presents a brief summary of mental health-related activities by leading international agencies.

Mental health in later life is promoted and protected by a range of factors. Protective personal attributes include positive self-esteem, self-efficacy, resilience and mastery. The positive psychological benefits of taking part in exercise is well established, especially in a group. There is a vast literature on the mental health benefits of social relationships, social networks and social participation. It is the quality rather than the quantity of relationships that is protective; having a confidante is especially important. Membership of an accepting faith community, having a meaningful occupation and a reasonable income are also protective. For people living with dementia important factors are social and family relationships; effective communication; and involvement in decisions. How older people protect their mental health is underexplored. Most older people regard prevention and promotion as conjoined; the two fields intersect. Risks and protective factors can be conceptualised as located in the individual, community and national/societal domains. In order for policy to engage meaningfully with preventing mental ill health in later life, it needs to address risks in all three domains and tackle the social determinants of health inequalities. Many risks to mental health in later life are a product of, and are embedded in, the lifecourse.

This chapter begins with a brief analysis of the ‘changing work paradigm’ in globalised economies and the evidence for the impact of this on mental health outcomes, particularly in terms of those who are or may become ‘precariously distressed’. This is followed by an account of structural stigma within mainstream mental health policies and the way in which they continue to reflect a risk agenda. The chapter then identifies the relationship between networks of risk in mental health and the networks of trust that have been negotiated between major constituencies, particularly between the state and relatives of victims of so-called ‘community care homicides’. The fourth and final section analyses in more depth the power of the lobby that broadly represents the latter group through the ‘organising power of grief’. The chapter concludes by explicating the circular and paradoxical nature of current policies. It is argued that they are liable to fail not only those citizens who require mainstream mental health services, but also the much larger number of people who, regardless of the reality of the risks, consider their lives and livelihoods as precarious and insecure.

Chapter 1 offers an overview of the UK’s socio-demographic and policy context. The UK has an ageing population that is increasingly diverse and heterogenous. Whilst for many older people health outcomes have vastly improved since the introduction of the welfare state, prevalence of ill health does increase with advancing age. The number of older people living with dementia is 850,000, a figure expected to rise to over 2 million by 2051. Disability, pain, chronic physical illness and dementia are risk factors for both depression and suicide. It is estimated that 30 per cent of older people have ‘depressive symptoms’ and that 1 in 8 of all suicides relate to older people. 4 per cent of older people suffer from ‘anxiety disorder’. Although not mental health problems as such, a growth of the number of older people experiencing isolation and loneliness, problem alcohol issues and social exclusion are contributors. In terms of policy, all four UK nations, have specific policies relating to dementia, on the one hand, and policies relating to preventing and treating functional mental health problems on the other. The former tends to be older age focused whilst the latter extends across the whole adult lifespan.

Almost all policy studies must begin by describing the domain with which they are concerned. This chapter applies the ‘embodied, inscribed, enacted’ heuristic to mental health in Scotland, showing how it provides a basis on which to characterize the mobilisation of knowledge in a specific policy context. In this instance, one of its most significant effects is to render visible the embodied knowledge of practitioners and service users. The ‘enacted’ component of the schema is shown to set the framework apart from other attempts to categorise knowledge, and it is the perpetual processing or enactment of knowledge in consultations, evaluations and working groups which distinguishes mental health policy in Scotland.

The introduction reviews the relevant histories of prisons, mental health policy, and the social welfare state. It highlights how recent scholarship has not connected the history of mental hospitals to the broader history of imprisonment. From Asylum to Prison frames historic mental hospitals as part of a broader carceral state and charts how the rise of mass incarceration shaped the closure of mental hospitals. Law and order politics served to criminalize mental health conditions and substance abuse. New prison construction in the 1980s took money away from mental health services and prisons absorbed many functions of the former mental health system. Finally, this history of deinstitutionalization offers lesson for people working to reduce mass incarceration in the twenty-first century United States. The introduction closes with a discussion of people-centered language and key terms such as institutions, carceral state, and mental illness.

This chapter addresses the paradoxes that the state is caught in, offering ‘modern’ care through the mental hospitals, with their obsolete designs, while phasing out indigenous healing systems. It builds on the claim that women do choose indigenous healing systems. It compares the two systems of care from the point of view of women, and links it up with debates within feminism. It shows the role of the state in its unquestioning support to psychiatry, presenting it as the only legitimate choice in addressing mental health needs of the population. The chapter focuses on implications of a transitioning mental health policy scenario post-Erwadi for the mental health needs of Indian women. It concludes by reiterating the urgent need to foreground women’s mental health seeking strategies and their choices as a crucial factor in formulating future mental health policy in the country. It highlights the possibility of choice in seeking traditional healing sites for emotional well being.

In 2007, a series of pilots of new forms of local service delivery in mental health care began in Belgium, called the ‘Therapeutic Projects'. This chapter describes the ‘Horizontal Consultation’ designed to integrate the results of these various local experiments with different user groups. It shows how mental health practitioners described and shared their different experiences and consolidated those experiences in documentary form. In doing so, it explores the relationship between the embodied-inscribed-enacted framework and Actor-Network Theory, or the sociology of translation.

The Ely Hospital scandal marks a historic moment in Britain, ushering in an avalanche of scandal in mental-health institutions that was to last for nearly fifteen years. This chapter traces the history of mental-health policy during this period and onwards to the New Labour government of 1997. It concentrates upon the interplay between social policy and scandal, employing three further concepts – scandal inflation, scandal fatigue, and policy hegemony – in an attempt to cast fresh light upon the relationship between the two dimensions. The institutional Reports of this period reveal the extent to which scandals relied upon routes other than official complaints procedures to bring them to light. Normansfield Hospital represents the end of the line for major institutional scandals in the field of mental health and marked the advent of community care.

The mental health recovery movement promotes patient self-determination and opposes coercive psychiatric treatment. While it has made great strides towards these ends, its rhetoric impairs its political efficacy. The authors illustrate how psychiatry can share recovery values and yet appear to violate them. In certain criminal proceedings, for example, forensic psychiatrists routinely argue that persons with mental illness who have committed crimes are not full moral agents. Such arguments align with the recovery movement’s aim of providing appropriate treatment and services for people with severe mental illness, but contradict its fundamental principle of self-determination. The authors suggest that this contradiction should be addressed with some urgency, and we recommend a multidisciplinary collaborative effort involving ethics, law, psychiatry, and social policy to address this and other ethical questions that arise as the United States strives to implement recovery-oriented programs.

The epilogue reflects on the contemporary crisis of mass incarceration in the United States, which has particularly affected people with mental health conditions and substance abuse disorders. It argues that today’s crisis is deeply rooted in the past history of mental health policy and offers a few main lessons for people working to make change. First, restrictive environments such as prisons and mental hospitals are inappropriate places to hold people on a mass scale. Second, it cautions people who are working to decarcerate prisons today. The history of deinstitutionalization proved that that cost-cutting cannot be the main reason for change, as it led to inadequate resources. People invested in prison reform should also be cautious that decarceration does not lead to new forms of restrictive environments, which happened during deinstitutionalization.

This chapter focuses on Chinese mental health service users in the UK and aims to illustrate how structural inequalities shape their recovery journeys. It starts with a discussion of the Recovery Approach with which the research critically engaged. It then introduces the diversity within the Chinese community in the UK. It selects two stories from the research to shed light on how, for UK Chinese people, inequalities such as class, gender, and ethnicity intersect at national and transnational levels, and impact on the way recovery journeys unfold. Such inequalities contribute to their distress and ill-health in the first place and could hinder their recovery. The implications for community development work with Chinese communities are then discussed.

In August 2001, twenty‐five people described as “mentally ill” and kept confined in a thatched hut near a Sufi healing shrine, perished in a fire in Erwardi, Tamil Nadu. The tragedy resulted in renegotiations of indigenous healing in India, pushing it to the social and epistemological margins, and diminishing the value of indigenous knowledge and healing practices, including spirit possession and exorcism. Different actors (the state, the Supreme Court, scientists, human rights bodies, media, local population) responded to the event with a rationalistic mind set of “educating the masses on mental health” and providing psychiatric, institution-based care. The chapter shows how these diverse actors aspired to occupy fresh ideational spaces perceived as “modern mental health care.” It argues that, in this decade of yet another version of the new, economically powerful India, there is a renewed effort to push the boundaries of the “modern” and the “traditional.”

Attorneys increasingly rely on the services of mental health practitioners. Although some practitioners lack training, the promise of professional rewards lead some to accept opportunities with resulting ethical quandaries. Due to significant differences between the objectives of traditional mental health services and expert testimony, problems occur when clinicians venture into forensic services. Attorneys and judges, unfamiliar with mental health specialties, may seek to press a mental health practitioner into multiple roles. Although not all multiple roles are ethically inappropriate, caution demands careful parsing of particular roles: (a) academic/behavioral science expert; (b) fact witness as a treating therapist; (c) expert witness based on a clinically oriented assessment; (d) pretrial and/or trial consultant; and (e) professional critic of other experts. Possible ethical issues and risks associated with accepting multiple roles are identified and strategies for avoiding or minimizing harm or exploitation are discussed.