mental health

Often overlooked and underfunded, mental health is a growing priority on the health agenda. Globally, suicide is the second learing cause of death amongst 15-29 year olds, and over 800,000 people committed suicide in 2012, leading to the issue gaining recognition in the SDGs.

In season one of My Perfect Country, we examined how suicide was tackled in Michigan. Below you can hear more from the key people behind their approach of screening for mental health issues.

War on Drugs?

In the USA, the War on Drugs has cost over $1 trillion, leading to many lives being wasted in jail for minor drug crimes. In the UK, this cost is £16 billion per year.

The Brookings Institute published a report in 2008 which compared three approaches to drug laws. The "punishment model" employed by the USA, the "depenalization model" used in Italy and Spain, and the "decriminalization model". It highlighted that the "punishment model" was least effective, and least beneficial to society as it leads to huge incarceration rates and massive cost to the tax payer.

Portugal took elements of the decriminalization model but went further, treating drugs purely as a health issue. Below, you can hear more from João Goulão, the orchestrator and implementer of Portugal's drug policy.

How the UK is learning from the Global South

UK-based charity Tropical Health and Education Trust was founded in order for British healthcare workers to support healthcare services abroad which have less resources. Despite being founded to aid other countries, they soon found that sending healthcare workers abroad also had massive benefits for them, as they picked up many skills, both practical and mental.

Being in resource-pressured environments, and learning from health workers who have lots of experience under huge pressure improves the efficiency upon their return to the UK. One GP said: “I’ve learnt more in five months about leadership and service development, and all these really key skills, than I’ve learnt in five years in the UK.” 76% of health workers who have been on this programme also reported improved leadership skills

Smoking

According to Cancer Research UK, 85% of smokers regret having started smoking

We spoke to health psychologist Felix Naughton on how health groups are making stopping easier by using smartphones.

Helping smokers at times of need using smartphones

Dr Felix Naughton CPsychol, Senior Lecturer in Health Psychology at the School of Health Sciences, University of East Anglia

Email: f.naughton@uea.ac.uk, Twitter: @felixnaughton

Comprehensive tobacco control policies include smoking cessation treatment, but there is a key factor that explains why many smokers fail to quit smoking that almost all treatments fail to adequately address. Ask a smoker when is the most difficult time for them to resist smoking and they'll most likely describe a specific time and situation. When they're stressed at work or when they are with their friends or family that smoke. Such specific situations contain cues, sometimes outside the individual's awareness, that generate urges to smoke. These 'cue-induced' urges develop as a result of learned associations between cue (e.g. friend) and consequence (smoking) and account for roughly half of all lapses to smoking when people are trying to quit. A key study* showed how half of all such lapses occur rapidly, within 11 minutes, after urge onset. All of this might not seem very surprising but it might be more surprising to learn that most formal smoking cessation treatments do not directly address these types of urges and high risk moments. Nicotine patches and Varenicline (Champix), the most commonly used smoking cessation medications, don't help in these situations. Faster acting nicotine replacements like gum and sprays can help, but these are less commonly used and often used inadequately. Studies have identified some effective psychological and behavioural strategies to help avoid or cope with cue-induced urges, such as avoiding other smokers, giving yourself a 'pep talk' ("I can do this") or going for a quick walk. But the problem is that relatively few smokers trying to quit make use of effective strategies when they are most at risk of smoking. However, technology may be able to plug this gap.

With all this in mind, we (a team of health psychologists and computer scientists at the University of Cambridge and University of East Anglia) developed an experimental context-aware smartphone app called Q Sense. The app is designed for smokers motivated to quit, who start using it approximately one-week before their nominated quit date. During this time, they log each time they smoke in real time, including the presence of key situational and psychological cues to smoke. At the same time, their smartphone captures the physical location of each smoking episode, using location sensors (e.g. GPS). If the person reports smoking twice in the same place, the app creates a 'geofence', a virtual perimeter, around that location. When their quit date arrives, the app triggers support messages in real time if and when they enter or spend time in any created geofences. Importantly, the advice and support Q Sense delivers is tailored to the smoking cues they are likely to be exposed to, based on what it learnt about their smoking behaviour via the logging system.

In a feasibility study,** we found smokers were engaged in the process of teaching the app about their smoking. It took them approximately 13 seconds each time to report smoking, including the presence/absence of situational cues, and for the phone to capture their location. There were times when the participants did not report smoking, either because they forgot, did not want to appear rude when around others or were constrained to use their phone (e.g. driving). Somewhat surprisingly, the participants did not indicate any privacy concerns about the location data the app was collecting, though the trustworthiness of the app developer was critical to this.

In a second larger study exploring the acceptability of Q Sense, we found that over three-quarters of participants said they would use the app again. One important question this study addressed was how long it took smokers to engage with real time support messages when in a high risk situation for smoking. Or put another way, it's one thing to have the technology to deliver support messages according to real time activities, but if people do not view those messages in a timely manner relative to exposure to smoking cues, this would not represent a very time-sensitive intervention. The study found that participants viewed 56% of the location triggered messages. So we were not always able to reach the participants. But for those messages they viewed, most were viewed within 5 minutes after delivery. So when people did engage, they engaged quickly. This is probably the first data indicating the speed of engagement of real time support delivered by a health app and shows we can support people quickly when they are at risk of unhealthy behaviours, though not all the time. The next important question for Q Sense is whether it changes smoking behaviour and promotes abstinence. Answering this question will require a large randomised controlled trial. But knowing we can reach people and deliver tailored support to them when they may be stressed at work or socialising with friends, and at high risk of smoking, is an important and exciting first step. A key benefit of apps like Q Sense, if proven to be effective, is their low cost and scalability, making them accessible to anyone with a smartphone across the globe.

Hyperlinks/references:

* Ferguson SG, Shiffman S. The relevance and treatment of cue-induced cravings in tobacco dependence. J Subst Abuse Treat. 2009 Apr;36(3):235–243. doi: 10.1016/j.jsat.2008.06.005. [PubMed]

** Naughton F, Hopewell S, Lathia N, Schalbroeck R, Brown C, Mascolo C, Sutton S. The feasibility of a context sensing smoking cessation smartphone application (Q Sense): a mixed methods study. JMIR mHealth uHealth. 2016 Sep 16;4(3):e106. doi: 10.2196/mhealth.5787 [open access http://mhealth.jmir.org/2016/3/e106/]

GUNS

Some countries see the wide availability of arms as a public health issue. Japan is a clear example of a country that has made sure that guns do not threaten public health.

Here we have more from crime journalist Jake Adelstein on the Japanese policy.

Photo: Raphäel Vinot

How Japan has almost eradicated gun crime

By Harry Low

Japan has one of the lowest rates of gun crime in the world. In 2014 there were just six gun deaths, compared to 33,599 in the US. What is the secret?

If you want to buy a gun in Japan you need patience and determination. You have to attend an all-day class, take a written exam and pass a shooting-range test with a mark of at least 95%.

There are also mental health and drugs tests. Your criminal record is checked and police look for links to extremist groups. Then they check your relatives too - and even your work colleagues. And as well as having the power to deny gun licences, police also have sweeping powers to search and seize weapons.

That's not all. Handguns are banned outright. Only shotguns and air rifles are allowed.

The law restricts the number of gun shops. In most of Japan's 40 or so prefectures there can be no more than three, and you can only buy fresh cartridges by returning the spent cartridges you bought on your last visit.

Police must be notified where the gun and the ammunition are stored - and they must be stored separately under lock and key. Police will also inspect guns once a year. And after three years your licence runs out, at which point you have to attend the course and pass the tests again.

This helps explain why mass shootings in Japan are extremely rare. When mass killings occur, the killer most often wields a knife.

The current gun control law was introduced in 1958, but the idea behind the policy dates back centuries.

"Ever since guns entered the country, Japan has always had strict gun laws," says Iain Overton, executive director of Action on Armed Violence and the author of Gun Baby Gun. "They are the first nation to impose gun laws in the whole world and I think it laid down a bedrock saying that guns really don't play a part in civilian society." People were being rewarded for giving up firearms as far back as 1685, a policy Overton describes as "perhaps the first ever gun buyback initiative".

The result is a very low level of gun ownership - 0.6 guns per 100 people in 2007, according to the Small Arms Survey, compared to 6.2 in England and Wales and 88.8 in the US.

"The moment you have guns in society, you will have gun violence but I think it's about the quantity," says Overton. "If you have very few guns in society, you will almost inevitably have low levels of violence."

Japanese police officers rarely use guns and put much greater emphasis on martial arts - all are expected to become a black belt in judo. They spend more time practising kendo (fighting with bamboo swords) than learning how to use firearms.

"The response to violence is never violence, it's always to de-escalate it. Only six shots were fired by Japanese police nationwide [in 2015]," says journalist Anthony Berteaux. "What most Japanese police will do is get huge futons and essentially roll up a person who is being violent or drunk into a little burrito and carry them back to the station to calm them down."

Overton contrasts this with the American model, which he says has been "to militarise the police".

"If you have too many police pulling out guns at the first instance of crime, you lead to a miniature arms race between police and criminals," he says.

To underline the taboo attached to inappropriate use of weapons, an officer who used his gun to kill himself was charged posthumously with a criminal offence. He carried out the act while on duty - policemen never carry weapons off-duty, leaving them at the station when they finish their shift.

The care police take with firearms is mirrored in the self-defence forces.

Journalist Jake Adelstein once attended a shooting practice, which ended with the gathering up of the bullet casings - and there was great concern when one turned out to be missing.

"One bullet shell was unaccounted for - one shell had fallen behind one of the targets - and nobody was allowed to leave the facilities until they found the shell," he says.

There is no clamour in Japan for gun regulations to be relaxed, says Berteaux. "A lot of it stems from this post-war sentiment of pacifism that the war was horrible and we can never have that again," he explains.

"People assume that peace is always going to exist and when you have a culture like that you don't really feel the need to arm yourself or have an object that disrupts that peace."

In fact, moves to expand the role of Japan's self-defence forces in foreign peacekeeping operations have caused concern in some quarters.

"It is unknown territory," says political science professor Koichi Nakano. "Maybe the government will try to normalise occasional death in the self-defence force and perhaps even try to glorify the exercise of weapons?"

According to Iain Overton, the "almost taboo level of rejection" of guns in Japan means that the country is "edging towards a perfect place" - though he points out that Iceland also achieves a very low rate of gun crime, despite a much higher level of gun ownership.

Henrietta Moore of the Institute for Global Prosperity at University College London applauds the Japanese for not viewing gun ownership as "a civil liberty", and rejecting the idea of firearms as "something you use to defend your property against others".

But for Japanese gangsters the tight gun control laws are a problem. Yakuza gun crime has sharply declined in the last 15 years, but those who continue to carry firearms have to find ingenious ways of smuggling them into the country.

"The criminals pack the guns inside of a tuna so it looks like a frozen tuna," says retired police officer Tahei Ogawa. "But we have discovered cases where they have actually hidden a gun inside."

Crime, Violence and the Japanese Gun Laws

Peter Squires, Professor of Criminology & Public Policy, University of Brighton

Japan is universally regarded as a low-crime, low-violence society although social scientific opinion often offers contrasting interpretations as to what has underpinned this low crime culture thus far (McCargo, 2004) and whether the low-crime culture is sustainable in the face of the pressures of globalisation and modernity.  Recently, rising crime and violence have been both cause and effect of these growing pressures

Amongst the reasons put forwards for the historically low rates of crime and violence in Japan are the relatively homogenous, affluent and traditional structures of Japanese society (Komiya, 1999: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1160570##).  Social relations are said to emphasise values of social order, collective solidarity, family honour, loyalty to one's immediate community and colleagues (these latter features reinforced by, until recently, the strong work group ethos and 'job for life' achievable in the Japanese employment market).  In turn, however, these features are thought to have weakened as global recessions have increased Japanese unemployment, destabilising communities and establishing new inequalities (Leonardsen, 2010).   

Japan is said to be a highly 'responsibilised' society in marked contrast to the liberal culture of personalised freedom which has characterised Western Societies.   At the same time Japan is said to embody a 'shame' culture (Braithwaite, 1989: https://www.amazon.co.uk/Crime-Shame-Reintegration-John-Braithwaite/dp/0521355672) in which the sense of responsibility for offence, fault or failure is internalised and borne by individuals.  This is said to produce a strong compulsion to obedience, a tendency to confess when accused of crime (some 95% of criminal cases are said to be resolved by guilty pleas) although, as Leonardsen has noted, with the fading of the Japanese economic miracle, a parallel tendency to blame victims for social problems, leaving burdens where they fall, has tended to erode a sense of collective well-being. 

These more 'cultural' features, or 'soft controls', are thought to have greater significance in restraining crime trends than the Japanese criminal justice system itself, although the police and criminal justice agencies have a number of distinctive and important features.  Police are generally held in high regard as authority figures, and they deliver policing services via a philosophy of paternalistic policing by consent.  The Koban system - or accessible police bureaux in urban areas are often regarded as a model for 'community policing' although many western observers would find the extensive Japanese police powers of stop, search, arrest and seizure some way beyond what would be tolerable in a democratic and rights-based vulture.  US observer David Kopel (1993: http://www.guncite.com/journals/dkjgc.html) refers to Japan as a seemingly consensual  'police state', where the police annually undertake a community census and 'every person is the subject of a police dossier'. 

Japan is regarded as having a relatively punitive criminal justice culture and although its rate of incarceration (47:100,000) is only a third of that of England and Wales although it also detains many people who might, in the west, have found their way into prison, in secure mental health facilities. Japan still retains the death penalty (supported by 86% of the public surveyed in 2009) although using it only occasionally (Hoyle, 2014: https://www.law.ox.ac.uk/centres-institutes/centre-criminology/blog/2014/01/death-penalty-japan).

Japan's low criminal violence rate is also explained - especially by American scholars - by reference to the exceptionally restrictive firearms laws in Japan.  Japan maintains a very low rate of firearm ownership and, correspondingly, has a very low rate of firearm violence and homicide.

A range of factors have conspired, historically, to suppress the demand for firearms in Japan.  In the first place, firearms were seen as unmanly and 'dishonourable' in a culture which favoured the samurai sword aesthetic; likewise, there was relatively little tradition of 'game hunting' and a reluctance to embrace foreign technologies (Kopel, 1993).  During the militarisation of Japanese society in the 1920s and 30s, firearms use was adopted as part of the military power of the state, but not as a civilian practice.  In the aftermath of WW2 and military defeat and demobilisation, Japan returned to a disarmed civilian culture (Law Library of Congress: http://www.loc.gov/law/help/firearms-control/japan.php).  Strengthened firearm regulations, culminating in 1958, with the Firearm and Sword Possession Control Law (enhanced in 1978, 1993 and 1995) imposed tough controls on all firearms and a virtual ban on civilian possession of handguns (Alleman, 2000).

In order to qualify for ownership of a rifle or shotgun, prospective shooters have to establish a clear sporting requirement for their firearm, attend firearm safety classes, pass written and firearm handling tests, undergo background checks, psychological tests and a medical examination, they undergo police interviews and have the police question family members, co-workers and neighbours as to your suitability and demonstrate satisfactory firearm security plan and safe storage of the firearm in the home.  In all this process takes about a year (Opelka, 2016: http://www.theblaze.com/stories/2016/08/31/think-getting-a-gun-is-tough-in-america-consider-japans-intrusive-nearly-year-long-process-to-own-a-firearm/).  Firearm licenses must be renewed every three years.

Such extensive tests and the relative disinterest of most Japanese citizens in firearm ownership have kept the number of firearms, legal and illegal, in circulation in Japan exceptionally low.  Other than their use by police and security forces, handgun ownership is the exclusive preserve of organised and career criminals (scarcity makes weapon traffickingprofitable for a few) and a recent upturn in gang-related shootings and Yakuza organised criminal 'hits' (Ogata, 2016) have led the Japanese Government to further toughen the penalties for illegal gun possession and 'more strictly regulate the flow of firearms into the general population' (Alleman, 2000).

Japan signed up to the UN Arms Trade Treaty finalised in 2013 but almost simultaneously declared a resumption in its arms exports, more recently Prime Minister Shinzo Abe controversially announced a reinterpretation of its constitutional principle of 'collective self defence' governing the deployment of Japanese military forces (commonly referred to as Self Defence Forces).  How far the changing global politics of security and counter-terrorism, Japan's uptick in armed criminal violence, tougher gun laws and the potentially changing role of the Japanese military can be seen through a single lens of weaponisation and militarisation remains an open question, but taken together these developments may suggest that Japan is no longer so immune to unsettling global trends as once it may have hoped.