I seem to have spent the most of my life travelling in various vehicles and with many companions across countries and organizations, across time and ideologies, cultures and societies. I learned a great deal on each of the stops of that travel – and understand now that I should have made detailed notes about what happened, when and why. Without notes I can only try to recall what went on but may make mistakes that those with a better memory or those who keep records will notice and, I hope, forgive.
My early years in Yugoslavia showed me that enormous advances in the health states of populations can be made if there is determination to do so. The years after the Second World War were the times of pride for public health in Yugoslavia. Malaria, typhoid fever, endemic syphilis and several other diseases were eradicated. Severe forms of child malnutrition culminating in a high prevalence of kwashiorkor syndromes vanished. Child mortality was brought down from being over 100/1000 to a decent 20/1000: of this enormous advance I was particularly clearly aware because my mother has been in charge of the maternal and child health programmes in Croatia and I witnessed her designing the programme and putting it into action. A network of independent outpatient institutions and dispensaries covered the country. The School of Public Health introduced a specialist degree in General Practice and offered it in particular to heads of the ‘homes of health’. Broad-scale prevention programs were introduced. Health care came free of charge to a huge majority of the population. The treatment of ‘social diseases’ (venereal and severe mental diseases, tuberculosis and some other infectious diseases) was free for all.
When I completed my training in psychiatry and neurology, I discovered that I had learned little about psychology and about ways in which people with mental disorders lived outside hospitals. That led me to enter an undergraduate (and then postgraduate) course in psychology and to become involved in epidemiological studies of mental disorders. A British Council scholarship brought me to London where I became aware of how large the similarities and dissimilarities of societies (and social contracts) could be within Europe and made me eager to learn more about cultures, the organization of scientific work, management of mental illness in the various countries across the globe and many more things.
In the mid 1960s, the Institute of Psychiatry at the Maudsley hospital where I was to spend my scholarship time was a popular training place for people from various parts of the world. Without much discussion about my expectations or future tasks, I was placed at the associated Bethlem Royal Hospital and told that I shall be seeing a patient in the mornings and go for courses to the Institute of Psychiatry in the afternoon. I was asked to see a patient, a young girl from London and to present her case to the consultant when ready and requested to do so. I did exactly that. I spent most mornings with my patient and various informants who knew something about her and her illness. Three weeks later, I was invited to present the case and got a lot of praise for the presentation. I asked what will happen next and was given another patient. I did not really want to spend my scholarship year to see 15 patients for 3 weeks each and then go home: so I asked who I could see to discuss the plans for the year ahead. My foreign colleagues (who were spending their time similarly) said that I should be patient and discuss this with the consultant to whom I was supposed to be showing cases. I attempted to do so but with limited success – perhaps, I was told this could be discussed after I have seen some more patients. This somehow did not seem sensible. I did not feel that I shall greatly benefit from seeing more patients from London and so requested an appointment with Sir Aubrey Lewis to discuss what will happen with me.
The interview with Sir Aubrey in 1965 was unforgettable. I was told by his secretary that I would have a very short time with him: we spent nearly two hours together and he asked me so many questions that in the end I knew more about myself than I thought possible. Our conversation covered all possible things. Sir Aubrey had an unquenchable thirst for information and I was very happy to be able to provide some of it. In the end, he made arrangements for my year at the Maudsley: these were complex but immensely helpful for my further work. I worked with Isaac Marks, Michael Gelder, Malcolm Lader and attended case reviews presented to Sir Aubrey and Michael Shepherd with whom I continued working while at the World Health Organization. I got a chance to see work with chronically mentally ill people supervised by Dr Bennett; and had the pleasure of meeting a number of younger colleagues– including John Cooper, Sir David Goldberg, John Gunn, Bob Kendell and others. Some of them became life-long friends and remained close collaborators in a variety of projects. John Cooper always ready to help, and a permanent source of wise advice made immensely useful contributions to the development of the ICD classification of mental disorders and other projects over many years. Michael Rutter with whom I had to work on the glossary of child mental disorders in WHO amazed me not only by his knowledge but also by the speed with which could write clear texts about complex matters. David Goldberg participated in key roles in a number of projects and we taught together many courses providing leadership skills to young psychiatrists. With some of the others I taught and collaborated in a variety of projects over the years always grateful to Sir Aubrey for opening the door to such a talented network of colleagues of good will.
During my stay in England, I learned a great deal about many subjects. I became co-author of several papers published in respectable journals and participated in a variety of projects. In 1965, Michael Shepherd asked me to see John Cooper, a key person in the USA–UK study and John invited me to become a member of the UK team in that study which explored reasons for differences in the hospital admission rates of schizophrenia and mood disorders in the two countries (1). The demonstration that most of the difference could be explained by psychiatrists’ assessments and that the differences that existed were to a significant degree an artefact left me convinced about the need to create a common language for psychiatry worldwide – a theme I was to pursue for many years while in the World Health Organization and afterwards.
Participation in the USA–UK study had side-effects as well. Before and after the series of assessments of patients in the Brooklyn State Hospital in New York, I visited a number of places of psychiatric interest. Henry Brill took me to the Pilgrim State hospital – then probably the largest mental hospital in the United States and possibly in the world – and told me about the management of such a hospital with 13 000 beds and 14 000 personnel. Jonathan Cole showed me the National Institute of mental Health where I talked about psychopharmacological treatment in Yugoslavia and remained speechless hearing how much money is given to research on mental illnesses. When visiting other institutions, I kept meeting psychiatrists who expressed their allegiance to psychoanalytic psychotherapy but – to my surprise – were harshly critical of any treatment that was not based on well-designed evaluative studies.
After the stay in London and the visit to the East Coast of the USA in connection with the USA–UK project, I returned to the University department of psychiatry in Zagreb, Croatia. I was eager to speak about things I had seen and learned, but my colleagues and superiors showed little interest in my experiences. I was not asked to make a presentation about my work during nearly the 2 years abroad. The work that I was to do was to be exactly the same as before my departure. In a way my time abroad was treated as if I had been away because of an illness. This made it very easy to accept an invitation to come to Geneva and help with the planning and conduct of the International Pilot Study of Schizophrenia (IPSS), a project that Tsung-yi Lin, a Taiwanese psychiatrist was to lead for the World Health Organization. The brain trust that planned this study had four members – Tsung-yi Lin, Erik Stromgren (then Professor of Psychiatry in Aarhus, Denmark) John Wing (then in charge of the Social Psychiatry Unit at the Maudsley) and Lyman Wynne (at the time leading a department at the National Institute of Mental Health in Washington). To be accepted by that group as one of its members was to realize a dream of participating in the planning of a major cross-cultural project and working on its realization with leaders of psychiatry whom I held in very high esteem.
After a few months in Geneva, I was transferred to India in 1968. There, I continued to work on the IPSS and in this connection visited project sites in India, Latin America and Africa. The mail was slow those days and although we used the diplomatic pouch my messages to Geneva about the project took a long time to get there and an even longer time to be answered. This left time to be filled and I visited all the mental hospitals and a variety of other institutions in India. A question that began to take form while I was there and grew in clarity and importance in time was simple to ask but remained, to this day without a satisfactory answer. I first thought that it was relevant only to the Indian situation but later discovered that it could be asked about psychiatry in many other developing countries. How was it possible that India had in all approximately 20 000 beds in mental hospitals and psychiatric departments in general hospitals (the number is still about the same) when by conservative estimates in India there were at least 10 million seriously mentally ill people who need in-patient care for at least 2 weeks a year? At least half the beds in the mental hospitals were taken by people who stayed there for a long time – and many of them were in hospital for reasons other than mental illness – for example because they had no place to go after their treatment was completed. Some of the mentally ill were probably placed in private institutions about which the government knew little and which for a foreigner were not easy to find or visit. Psychiatrists in India did not describe such private institutions and did not seem to be aware how many beds and of what quality there might be in such places. Some patients were probably living as vagrants or beggars and others were undoubtedly in prisons. Still, with all these calculations – and taking into account that the incidence of severe mental illness such as schizophrenia in India did not differ from that in other countries and that there must have been more people with various forms of brain damage due, for example to poor perinatal care, infectious diseases and malnutrition in childhood than in Europe – it was not clear what was happening with the millions of people who were acutely ill and who needed help and more millions whom mental illness left impaired and unable to look after themselves. Premature mortality – because of violence to which the mentally ill are so often exposed, self-neglect and absence of care for physical illness might also be of importance, I thought – but in the follow-up studies of the people included in the WHO schizophrenia studies the mortality of people with schizophrenia was not very different from the mortality in other countries. The extended family system might explain a part of the puzzle – but not all of it: in surveys families did not have as many mentally ill people in their midst as could be expected if most of the mentally ill were cared for in this way. I hope that someday I shall learn what the answer to the puzzle might be – for the moment I am still not satisfied with the answers proposed.
Meanwhile, in Geneva disagreements among the personnel in the Mental Health Unit resulted in the departure of Tsung-yi Lin, the Medical Officer responsible for epidemiological and social psychiatry to the USA and of Dr Pieter Baan, the Chief of the Mental Health Unit, back to the Netherlands. I was called back from India and given the responsibility for the sector that Tsung-yi Lin had been leading. He had envisaged a programme that would start with pilot studies to develop assessment instruments, continue with epidemiological studies of geographically defined populations and end with a programme of training in epidemiological psychiatry that the centres taking part in the first two phases would provide (2). In parallel, a programme was to explore ways of improving the classification of mental disorders. The latter programme was conducted by having a group of internationally recognized leaders of psychiatry (the ‘nuclear group) meet once a year with 15–20 leading psychiatrists in different parts of the world to discuss the diagnosis and classification of a particular group of disorders. A key element of these meetings was the presentation of case histories and video tapes which the experts had to study in order to reach a diagnosis (3). They usually disagreed on the diagnoses of these cases which then became the basis for the discussion about the best way to define disorders and organize the classification. The nuclear group was carefully composed by having members highly placed in the professional world and from countries that played the most important role in the provision of budgets and governance of the WHO – with two USA citizens (K. Ewald and M. Kramer), two USSR representatives (Shneznevsky and Serebrjakova) and one each from France (R. Sadoun), UK (M. Shepherd) Latin America (H.Rotondo), Scandinavia (O. Odegard) and Japan (M. Kato). The programme resulted in a variety of recommendations concerning the classification of mental disorders but also demonstrated the usefulness of using videotaped and written case histories to demonstrate to the leaders that they too can be wrong and that there was a need for operational criteria that accompany a classification of mental disorders (4).
The IPSS proved to be not only an endless source of interest and hard work but also another door to the world of international psychiatry and epidemiology. The experts leading teams that were engaged in the IPSS were among the profession’s elite in their own country and worldwide. In the nine centres that participated in the IPSS more psychiatrists, social workers and psychologists examined more than 1200 patients using standardized methods, including the Present State Examination PSE (8th Revision) which later developed into the Schedule for the Clinical Assessment in Neuropsychiatry (SCAN) and several other instruments to assess the level of disability, the psychiatric history and the social adjustment of the patients included in the study (5). The study demonstrated that the syndrome of schizophrenia can be found in all the cultures from which the patients came and that psychiatrists from different countries, different schools of thought and in different and often politically separated countries can work together and use standardized instruments in a reliable way (6). Forty years later, these two findings do not surprise. At the time, however, they were considered no less than amazing. The third finding – that schizophrenia in people in developing countries has a milder course and better outcome than in the developed world (5) was equally unexpected and led to further work aiming to confirm or refute this finding by an examination of a further 1300 patients that were found in an incidence study (7) in the same and some additional centres, located in Chandigarh, Dublin, Honolulu, Nagasaki, Nottingham and Rochester.
This study confirmed the findings of a better outcome of schizophrenia in developing countries and showed that the incidence of sharply defined schizophrenia does not differ between the countries included in the study. A long-term follow-up of people with schizophrenia identified in the course of the IPSS and the study of Determinants of severe mental disorders again confirmed that the outcome of schizophrenia in the developing countries is better than in developed countries, a finding that still awaits full explanation (8). The WHO studies of schizophrenia were by far the largest collaborative studies in psychiatry in their time and in addition to their contribution to knowledge had the merit of opening the door to other international investigations whose design and management were often inspired by the experience gained in WHO’s studies.
A few years later in 1971, I became the head of the Mental Health Unit which was then – with the great help of T. A. Lambo (a leading psychiatrist who was involved in the WHO studies of schizophrenia and became the Deputy Director General of WHO) – elevated to the level of an Office in 1974 and soon after that, in 1977, became a Division which I directed for the next 17 years. These changes from Unit to Office and from Office to Division might sound bureaucratic, but they placed mental health matters on the same level as the traditional foci of work of the WHO. The budget of the new Division was modest, an expression of the widely held conviction that psychiatry has little to offer to the public health enterprise: but it was a Division, the highest technical level in the WHO. Financial support for some of the projects of the new Division came from grants obtained from the National Institutes of Mental Health, Alcohol and Drug abuse and from other agencies within the UN system and outside of it: the most important support however came from a very large number of colleagues in developed and developing countries who offered their time, staff and influence to the programme without receiving any money for it. This helped to mount a large number of studies on a variety of topics of scientific and public health interest (9, 10). Leaders of biological psychiatry carried out a number of collaborative studies and participated in a variety of educational events. A major study examining the possibility of extending mental health care by educating primary health care personnel demonstrated that such a strategy was possible and well received by all concerned. Started in 1973, 5 years before the Alma Ata conference on primary health care in Senegal, Colombia, India and the Philippines, the study opened the door for other studies of the best way to provide mental health services particularly in developing countries (11). The demonstration that mental health care can be provided in the framework of primary health care was trend setting. The results of WHO’s study and expert committee meetings (12) that supported these findings made the governments and many leaders in psychiatry realize that it is possible to develop mental health programmes despite the scarcity of highly trained psychiatrists and other mental health experts. WHO’s position served as a support to those who wanted to build mental health programs in developing countries and had an influence on decision-makers in many of the developed countries which hesitated to introduce mental health elements into primary health care services.
The IPSS and the Study of Determinants of severe mental disorders mentioned earlier was followed by a study of disability in different cultures (13) and by retrospective studies of schizophrenia in India, China, Hong Kong and elsewhere (8). A study of depressive disorders in different cultures demonstrated that comparative studies of depressive disorders in different cultures are possible and that the outcome of depression with ‘melancholic’ features is somewhat better than that of depression with ‘neurotic’ characteristics (14). Other major international studies focused on the psychological functioning after HIV infection (and before the occurrence of AIDS (15, 16). That study was also a first in many ways: in contrast to previous work it studied changes of cognitive functioning in male and female subjects, in developed and developing countries and in heterosexuals as well as homosexuals. A multi-centric study addressed psychological consequences of female sterilization (17). In the area of alcohol and drug abuse, it was possible to produce a series of reviews of evidence and publications that helped to ensure that findings of research on substance abuse reach the United Nations bodies dealing with that topic.
The Division’s projects were producing a steady stream of results and publications in high impact journals; but, perhaps more importantly they contributed to the creation of networks among people interested in the field of mental health, the world over. The meetings of investigators were for all intents and purposes meetings of friends who respected each other and liked working together. The links between the investigators and their teams in different centres did not stop when the studies were completed: they continued to help in other studies with and without WHO’s input and involved work and friendship among investigators and their families. Recently the grandchildren of one of the investigators decided to spend, once more, holidays with their peer grandchildren thousands of miles away; hearing this, I felt that efforts that I put in building the networks were well worth it. A number of the centres that participated in the WHO mental health programme were recognized by the World Health organization and national governments as WHO Collaborating centres: in all, these came into existence in more than 30 countries and continued their collaboration long after the WHO projects were completed.
Some of the staff of WHO dealing with mental health working with me over the years were located in Geneva and others were in the Regional Offices of WHO in Brazaville, Cairo, Copenhagen, Manila, New Delhi and Washington. There are too many to be listed by name, but I am grateful to all of them for their many contributions to the programmes and for their support. With one or two exceptions they were all young when recruited and all very able. I thought about them – and about the participants in the programme who were not on staff, in an old-fashioned way, as a family or as childhood friends. This might not have been the right way to view collaborators in programme sponsored by an international intergovernmental organization – but it made a lot of sense to me and acted as antidote to many of the administrative and bureaucratic constraints that we had to face.
An area of particular interest and a major opportunity to make a difference were the revisions of the International classifications of mental disorders. The 8th Revision of the International classification of diseases (ICD 8) was just published when I came to WHO in 1967, and it took considerable effort to convince all concerned that the section dealing with mental disorders must be handled differently from most other sections because of the differences in the interpretation of diagnostic terms that labelled the categories of the ICD. We were then given the task to produce a glossary – a description for each of the categories of the Chapter that dealt with mental disorders. Sir Aubrey Lewis – who was the principal writer of the glossary that accompanied the classification in the UK – came to Geneva and I had the pleasure of working with him on the glossary that was to accompany the 8th revision of the ICD. Soon after the publication of the booklet containing the definitions – that were also included in the official volume containing the Revision – we had to start working on the 9th Revision – which was very similar to the previous version. The success of the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM 3) that took the bold step of defining the categories not only by a description but also by operational criteria seemed to indicate that a definition of operational criteria for psychiatric diagnoses might be the right way to arrive at a globally acceptable common language for psychiatry. Gerald Klerman, then Director of the Alcohol, Drug Abuse and Mental Health Administration of the USA was of the same opinion and felt that WHO was the agency that could take on this task. He facilitated the formulation of a cooperative agreement that made it possible to convene a series of expert meetings that reviewed current knowledge and made recommendations about the changes of the classification. A major meeting in Copenhagen followed and produced guidance for the revision of the mental disorder chapter of the ICD as well as recommendations for research and education that should go hand in hand with the changes of the classification (18, 19). The subsequent years allowed the build-up of a network of experts that continued working on the drafts of the 10th revision of the ICD mental health chapter and of instruments that could serve to assess the mental state and reach a diagnosis. Darrel Regier, a psychiatrist of great ability, insight and vision, then at the National Institute of Mental Health (NIMH) of the USA, some of his colleagues, including Jay Burke, were immensely helpful in this process, providing wise advice, shepherding the cooperative agreement with the NIMH and creating opportunities for discussions with the group that was producing the drafts for the DSM 4. The results of these efforts were important in many ways. The 10th Revision of the ICD chapter of mental and behavioural disorders and the DSM 4 classification came very close and thus indicated that the dream of a common language for psychiatry is within reach. The work on the classification and later on the educational activities carried out to ensure its correct use also led to the development of a network of centres which were to follow the developments and be ready to present recommendations based on experience and new evidence for the 11th Revision.
The mental health programme was also engaged in health policy formulation and undertook a variety of educational projects ranging from the production of guidelines and educational texts to series of educational meetings and fellowships. It produced a large number of assessment instruments in various languages focusing on mental disorders, disability, quality of life and the functioning of mental health services (20).
Data from WHO studies and the wisdom of WHO mental health networks also contributed to the formulation of numerous resolutions and recommendations of the WHO Governing bodies, both at the global and at the regional level. These resolutions and the participants in WHO’s work influenced country mental health programmes that were formulated in growing numbers over the years: up to 1970, less than 5% of the world’s countries had such programmes; in the decade of 1971–1980, 8% of countries produced them; in the period 1981–1990, another 26% of countries and in the years 1991–2000 another 51.2% (21).
Overall, the period at WHO was very busy and highly productive, despite the nature of a large international organization and continuing financial scarcity that the programme had to face. We were engaged in policy making, consultations and education. We also carried out research, although the WHO administration did not see research as a legitimate or important part of technical programmes. Yet, we continued doing research because WHO’s international status made international and transcultural research more easily possible for it than for any other institution. There was another important reason for the mental health programme’s engagement in research: research was the fastest way to make the mental health programme known and followed by the professional community and through them by the government officials and structures that were supposed to be WHO’s partner in health promotion. In addition, by being a world leader in international collaborative research, the WHO mental health programme was contributing to knowledge and to the development of collaboration across national borders and political divisions.
I left WHO in 1993 before retirement age partly because I preferred that people ask me why I had already left rather than why I was still there. I also wanted to show that I was not addicted to whatever power the position of Director of a programme has but that I was willing to help the programme along without being its head. Things turned out differently and my collaboration in the mental health programme of WHO became sporadic and non-intensive. Meanwhile in 1993 I was elected President of the World Psychiatric Association and that brought me into another set of networks and preoccupations which had much less to do with national health policies and public health efforts. In this new setting, the preoccupation with mental health services in the third world countries was less clearly present. With some exceptions, the recommendations of the WHO and the policy that were formulated jointly with governments were unknown or not considered sufficiently important to be discussed.
Private psychiatry that had been at the periphery of WHO’s interest was centrally present in the setting of WPA and other professional organizations. In many countries, private practice psychiatry was the main source of psychiatric care – particularly if one did not count the mental hospitals which were providing custodial care, yet WHO’s policies and recommendation gave very little if any prominence to the private sector, an omission that probably made planning for mental health care less well informed and less likely to succeed. This was not only the case for the mental health programme; WHO in general, in all of its programmes paid little attention to the private sector – as style of work that is perhaps understandable because WHO is an intergovernmental organization but certainly not justifiable if the size and importance of the private sector is taken into account. The awareness of the importance of health-care industry – ranging from ambulance car production and sleep measurement apparatus to pharmaceutical and insurance companies – was omnipresent. Meetings of psychiatrists were organized in a manner that minimized absence from the (usually private) clinic and congresses were planned with an eye on the interest that industry might have in the topics that will be addressed. The industry was often the only source of money that made research – or the attendance at congresses abroad and even in the home country possible. The leaders of psychiatry in many countries had close connections with industry representatives and that increased their power because they could influence the distribution of funds from industry. There was incomparably more interest in treatment and its refinements than in the prevention of mental illness or in service organization. Specialized sections of professional organizations often assembled the most important experts and organized meetings of splendid quality. Their preoccupations, methods of work and fields of interest were so different from each other that I sometimes wondered whether the specialties within the profession of psychiatry still have enough in common to belong to psychiatry as a single discipline. While at the World Psychiatric Association I had to learn new ways of managing programs but could also use what I learned while working with WHO over the years. My first task in WPA was to help re-write its statutes – an act symbolizing the change of the WPA from a rather informal organization plagued for many years by problems related to the abuse of psychiatry in the Soviet Union to a more task-oriented association. J.J. Lopez Ibor, a long-time friend, Secretary General and later President of the WPA described this as a change from the Bourbon to a Habsburg style of work and perhaps this was a good simile (although not being a member nor confidant of the Habsburg family I am not certain that the Habsburgs would have accepted the structure we wanted to build). More importantly however during my time at WPA we managed to start a global programme against stigma and discrimination because of schizophrenia (22) which involved some twenty countries and was highly successful. We also developed several comprehensive sets of training materials for psychiatrists and general practitioners – on schizophrenia, depressive disorders (the updated version of that programme has been published last year (23) and the use of the International classification of diseases. The traditional role of WPA – to convene meetings of psychiatrists was not neglected either – and in the course of my presidency some 40 000 psychiatrists attended WPA meetings.
In the decade that has gone by since I served as President of the WPA and of the European Psychiatric Association (1999–2009), I focused on four topics, each one of them requiring much more time that I had or have. The first of these is to manage and lead the series of courses on leadership and professional skills for young psychiatrists in various countries. These are very intensive and require a lot of preparation but are continuing to delight me because they are offering me a chance to meet many young people with vast talent and creative power in many countries and to remain optimistic about the future of psychiatry. I continue to be engaged in several projects dealing with stigma of mental disorders, and am greatly encouraged to see that stigma of mental illness can be reduced or prevented (24). Second only to the reduction of stigma of mental disorders as a major challenge for psychiatry today is undoubtedly the co-morbidity of mental and physical disorders, and I have become actively engaged in work that aims to create awareness of the magnitude and severity of this problem and to develop and implement strategies that could reduce it. We started by a production of a series of books that brought together existing evidence and should serve as the basis for action programmes – the first of which dealing with co-morbidity of depression and diabetes has recently started. The books published so far cover physical illness and schizophrenia (25); intellectual disability and health, (26) physical illness and drugs of abuse (27); depression and diabetes (28); depression and heart disease (29); and depression and cancer (30). I am also pleased to have opportunities to contribute to work on issues related to the creation of the 11th Revision of the ICD and the 5th Revision of the DSM, thus maintaining the hope that one day psychiatry will not only use a common language but also speak with one voice and say many things that will be useful to the improvement of health of the world’s populations.