Nickels Blog

From Dr. Sam

Dear Friends,

BLOG #3, November 2017

El Salvador’s first ever MENTAL HEALTH LAW

In 2009, El Salvador’s Ministry of Health (MoH) wrote its first mental health policy to guide work in the area of mental health. In 2014, ACISAM (our lead partner in El Salvador) and CHHD were asked to comment on the proposed 5-year revision of the policy. At the same time, the MoH began work on a Mental Health Law (MH Law). The difference is that a law carries more weight, especially with the national assembly in order to obtain more funds for mental health programs on a national basis. ACISAM and CHHD both contributed through meetings with the MoH and the National Forum for Health Reform to help develop the law. Our contributions focused on pushing the government to focus on community-level mental health services, ensuring inclusion of users and family caregivers in policy and decision making, and increasing support from the government for user and family associations and their work. On June 29, 2017, this law was finally passed by the national assembly (Decree 716). The passage of a mental health law is an important policy victory, one that has been advocated by the World Health Organization for low resource countries in order to improve services and human rights for persons with psychosocial disabilities.

Analysis. The MH Law has many strengths: the foundation of the law is human rights; the law requires the departments of education and justice and security to carry out training programs related to mental health and human rights; it calls on the departments of social services, labor, and the military, to be aware of and implement the MH Law within their departments; the law calls for attention to be provided to families and communities (not just patients); the law recognizes and emphasizes the need for psychoeducation and rehabilitation (not just medication); the law calls for primary and other basic health providers to screen for mental health needs; it states that all doctors should be trained to provide basic mental health services and have access to medications appropriate for their patients; general hospitals should also have units available to manage persons with mental disorders; the ministry of health should promote research in mental health as a key element for technical and political decision making, and integrate best practices from national and international sources; the law states that everyone has the right to participate in planning and evaluation of MH services at the policy level, with a focus on community level services; patients have the right to receive non-pharmacological treatment; the right to be accompanied by family before, during and after treatment, and for the patient and family to be told what the diagnosis is; to receive treatment free of stigma and discrimination; to receive individualized treatment in an environment that respects the patient’s privacy; the right to be admitted to a health clinic or hospital voluntarily under doctor’s consent after diagnosis or recognition that one is a danger to oneself, or to be admitted to the national psychiatric hospital with consent from oneself, family or responsible party; the right to medications to ensure stabilization and recovery; and the law clarifies that families and caregivers also must respect the rights, equality, and individual autonomy of each patient, so as not to discriminate against their own family member. In terms of the family, the law states that the family has the right to have its needs met too—for assistance and training, from both government and private providers of mental health services.

The law calls for four strategies to be implemented for the general promotion of mental health. These are closely aligned with the goals of our Family to Family program, and provide an excellent opportunity and justification for partnership between ACISAM and the MoH to accomplish mutual goals. The four mental health promotion strategies include: education based on scientific evidence, social communication about mental health, creating spaces for social participation in the promotion of mental health, and promoting attitudes among health personnel and community members for working in solidarity to accomplish goals for mental health.

Weaknesses. In our opinion, weaknesses in the new law tend to reflect a concern by the MoH that families take more responsibility and follow through on instructions, rather than a focus on the government’s responsibilities. For example, “patients and families should comply with treatments and therapeutic measures defined by health personnel”; and “families related directly to the patient will assume the responsibility to comply with the treatment, transportation, and care of the patient as indicated by the doctor.” However, the law does not indicate that patients have the right to choose their treatment, or that health personnel must provide patients with information on all the potential treatments available. Nor does it state the government’s responsibility to help families access treatment, for example, by decentralizing services. Without greater decentralization, the burden of cost and time becomes a significant barrier to families accessing services. The law calls for day programs, therapeutic communities (group work and therapy at the community level), and other best practices, but “according to the available resources.” In other words, it does not call for new or increasing resources, and it does not call these best practices rights, which in turn might require the government to provide the necessary resources. While it does call for “modernizing mental health services in the country,” it does not define what this would mean or look like.

Conclusions. The passage of the Mental Health Law in El Salvador is a major achievement for the Ministry of Health and for mental health advocates in the country. The MH Law should be usable as a tool to improve human rights, set higher standards for care, and encourage the government to more adequately fund mental health services, including greater access to medications. While the law has many strengths, including assuring certain patient rights, a focus on inclusion of the family, education at the community level, the provision of services at the community/primary care level, and a call for training in MH for government agency personnel, there still exist weaknesses in the MH Law. Principal among these are a focus on family responsibility rather than the government’s need to decentralize services to reduce access barriers. Nor does the law call for increased funding to address the shortage in medications, mental health personnel, community level services, and other needs.



BLOG #2, August 2016

Anti-psychotic medication – first or second generation?

This question is very important for users and family caregivers around the world. We want ourselves or our loved ones to have the best medicine to help in the recovery process and to be able to work.

We often think that if there are new drugs, they have to be better, and this is what the ads from pharmaceutical companies tell us. But it is true? It is an important question because the cost is very high for many new drugs.

Researchers in global mental health have begun to investigate these questions. Some studies show no difference between the impact of first and second generation mental health medications. But there are differences.(1) For example, first generation meds are cheap and often have very unpleasant side effects. The second generation meds can cause weight gain and secondary problems of other diseases such as diabetes, lipid increases, and heart or cardiovascular problems.(2)

In a recently published study from Germany (Effects of anti- psychotics of the first generation versus second generation in the quality of life of people with schizophrenia. A randomized, double-blind study, by Grunder et al, 2016)(3) the authors say studies in the last 10 years have not strongly shown the superiority of the second generation antipsychotics (SGA) over the first generation of antipsychotic (FGA). In this study, 136 adult patients received FGA (haloperidol [3-6 mg] or flupentixol [6-12 mg]) or SGA (aripiprazole [10-20 mg], olanzapine [10-20 mg], or quetiapine [400-800 mg]) randomly selected.(4) Subjects were followed for 6 months and measured quality of life (SF-36 and CGI-I), weight (BMI), and number of hospitalizations.

The results showed adverse events (hospitalization or capacity reduction function) were higher for patients given SGA (57%) vs. FGA (48%). Self-report quality of life was better for patients given SGA vs. FGA measured by SF-36, but there was not a difference (benefit) between the two groups as measured by CGI-I. There was weight gain for patients given SGA. The authors concluded that 1) the quality of life is better for patients given SGA, but 2) one has to balance this benefit with metabolic problems (side effects) of some SGA.

What does the World Health Organization (WHO) say? “New” atypical “antipsychotics given to patients have an effect equal to, but are more tolerable than, conventional neuroleptic drugs”(5) The WHO manual “mhGAP”(6) is a mental health treatment manual for use by medical and other staff in primary care clinics where there are no psychiatrists in low-resource countries. The manual states: If you do not respond well to more than one typical antipsychotic (FGA, such as haloperidol, chlorpromazine, and fluphenazine) for a while and with sufficient doses: 1) review the diagnosis, 2) ensure that it is not a result of using alcohol or other drugs, 3) ensure-the patient is taking the medication, 4) consider increasing dose or change medication 5) think of atypical antipsychotic (SGA) if the cost and availability is not a constraint, and 6) use clozapine for those who do not respond to any other antipsychotic drug.

What can conclude from the perspective of users and family carers? It is clear that the situation is complex. The options depend on access to all medicines, and this depends on costs. But one can not say that the SGA are better than FGA. It is best that each patient and family work closely with your doctor, provide your doctor information about the side effects and how they change over time, and clearly discuss the problems of other diseases that affect the patient. Because each person responds differently to medications, this process can take time, sometimes years, to find the best medicine. And over the years, sometimes the effect of medications on a person change as well, becoming less effective, or growing in side effects. One has to have patience with the process, with drugs, and with the patient.

We must always remember that the drug is never enough. Patients need support, education, understanding of their families, and programs for the recovery of self-esteem, friends, and work. Above all, love always works.

Dr. Sam

Notes and References

Dr. Sam is Samuel Nickels. It is not a psychiatrist or psychologist. He is a researcher of mental health, a social worker, and a family caregiver with a brother who has schizophrenia. You can respond to blogs directly to the web site, or contact Dr. Sam (SamuelNickels @

1 Royal College of Psychiatrists’ Public Education Editorial Board. (2014). Antipsychotics. Royal College of Psychiatrists. Available free online.

2 Meltzer HY, Davidson M, Glassman AH, Vieweg WV. (2002). Assessing Risks versus clinical cardiovascular benefits of atypical antipsychotic drug treatment [cardiovaculares diagnose clinical risks versus benefits of treatment for atypical antipsychotic drugs]. Journal of Clinical Psychiatry, 63, Suppl 9 25-29.

3 Grunder, Heinze, Cordes, et al. (2016). Antipsychotic effects of first generation versus second generation antipsychotics on quality of life in People with schizophrenia: A double blind randomized study [Effects of antipsychotics of the first generation versus second generation in the quality of life of people with schizophrenia: a randomized double studio blind]. Lancet Psychiatry.

4 Haloperidol, known as Haldol. Flupentixol, known as Depixol. Aripiprazole, known as Abilify. Olanzapine, known as Zyprexa. Quetiapine, known as Seroquel.

5 Chisholm, Gureje, Saldivia, et al. (2008). Schizophrenia treatment in the Developing World: an interregional and multinational cost-effectiveness analysis. Bulletin of the World Health Organization, 86 (7). 497-576.

6 World Health Organization. (2010). mhGAP intervention guide for mental neurological and substance use disorders in non-specialized health settings: Mental Health Gap Action Programme (mhGAP). Disponsible in Spanish free online (




A new Blog on the Family and User Movement for Mental Health in Central America

I’m tickled to finally begin a blog, something I’ve been thinking about for a while. Blogs by Tom Insel, the director of the U.S. National Institute of Mental Health, the Mental Health Innovation Network, and other bloggers have taught and inspired me. The focus of this blog will be reflections on issues of import to users of mental health services (“users”) and their families and caregivers.

I will focus on the international scale and on issues of relevance to the work of our organization in Central America with users and families there. One study (Creating high impact nonprofits, 2007) discussed how strong nonprofits combine SERVICE with ADVOCACY to increase their impact. Advocacy is important because it can help us address root causes, involved the government in partnerships, change laws, and increase funding for programs. It can also empower people with disabilities and their families as strong advocates for themselves.

One of the current big advocacy issues is the need to include mental health treatment in the new Sustainability Development Goals. From 2000 to 2015 these goals were referred to as the Millennium Development Goals (MDGs), an effort by the U.N. to help countries focus on the important issues—for example, reducing infant mortality, eradicating extreme poverty, and achieving universal primary education. These goals have been strong motivators to countries and foundations working globally. For example, El Salvador now provides free primary education for all its children.

However, MDGs do not mention mental health. This was a result of stigma and a lack of understanding about how prevalent mental health problems are and how important it is to a person’s health to treat both her physical and mental health problems. For example, people with heart disorders often suffer depression and people with common mental disorders may miss taking their diabetes medication.

The next round of global goals for development, called the Sustainable Development Goals (SDGs), are in the process of being revised now. This is our opportunity to advocate for inclusion of mental health on the global development agenda.

This will have a tremendous impact on how governments and foundations the world over fund development and health programs over the coming 15 years. Here are a few ways you can advocate.

  1. The U.N. has a fun web-link where you can choose 6 priorities for the new SDGs. Be sure to go to the bottom of the page under “Suggest a Priority” and list MENTAL HEALTH, then go back up to choose 6 other priorities. The site creates a mini-video for you with your priorities listed:
  2. You can write the two U.S. leaders listed below. Just tell them “I want mental health included in the Sustainability Development Goals!” Or you can fill out and email the template at this link: ( )

The Honorable Samantha Power                                                          
U.S. Ambassador to the United Nations
799 United Nations Plaza, New York, NY 10017 (online via form:

Secretary of State, John F. Kerry
U.S. Department of State
2201 C Street NW, Washington, DC 20520 (online via form:

  1. You can show your support on the following global mental health website by listing your name and/or organization as supporting this effort to include mental health in the new SDGs:

 Thanks for making your voice heard!

Sam Nickels
Director, Mental Health International
A project of the Center for Health and Human Development

PS… Here’s the message I sent to Amb. Power at the UN and Sec. Kerry at STATE DEPT:

Please include mental health among the new Sustainability Development Goals. 1 in 4 people in the world suffer from mental illness. Comorbidity is high between physical and mental illnesses – we cannot address one without the other. 3000 suicides occur daily around the world and depression is the leading cause. People with mental illness suffer higher rates of unemployment than any other kind of disability group, so they and their families are among those who suffer the highest rates of poverty. Effective treatments are available and recovery is possible–if they have the needed supports.