A patient at Ammanuel Psychiatric Hospital, Addis Ababa, Ethiopia
Developing nations must stop aping the North's mental health services and use strategies tailored to their own needs, says Vikram Patel.
Is mental illness really a public health problem in developing countries? Certainly, there is no mental health equivalent today of the enormous global initiatives for infectious diseases, child health or, more recently, non-communicable diseases such as heart disease.
But although the appalling lack of global interest suggests otherwise, the straightforward answer to the question is, unambiguously, yes. Clear evidence, such as that from the major World Mental Health Surveys, shows that mental disorders are highly prevalent in many low- and middle-income countries.
A common myth, even among those who accept that mental disorders are prevalent in poor countries, is that these illnesses cannot be treated affordably. There is now much evidence that this is not true. Despite this, the treatment gap — the gap between the number of people with disorders and the number who actually receive evidence-based care — is as high as 70 to 80 per cent in many developing countries.
A key problem is that mental health services in developing nations imitate those in the West, where specialists in clinics or hospitals treat patients. This works well when there are enough specialists, and importantly, enough hospitals. When both are in short supply, more innovative thinking is needed. I believe non-specialist healthcare workers should become the front-line of mental health services in poor countries and be incorporated into the core of mental health provision.
Mental health disorders encompass diverse conditions and ages, from autism and mental retardation in early childhood, substance abuse and schizophrenia in adolescents, depression and bipolar disorder in adults, to dementia in older people. Their frequency varies greatly between populations and between specific groups of the population. For example, the rates of depression can vary five-fold between different populations, and within a population women are 1.5 to 2 times at greater risk than men. Reasons for these variations remain unclear.
Apart from the mental anguish these conditions bring, mental disorders have a big effect on other health issues, and on the social and economic opportunities of the sufferer.
For example, depression in mothers affects how their children develop, mental retardation in children makes it harder for them to complete their education, and schizophrenia in young adults increases their risk of early death.
Closing the treatment gap
The biggest challenge is that most mental health professionals in the developing world (psychiatrists, clinical psychologists, psychiatric nurses and social workers) seem uninterested in responding to the treatment gap. And it is clear that, because of scarce mental health resources, and their iniquitous distribution and inefficient use, developing countries will never be able to close the treatment gap in any significant way if business continues as usual.
What is business as usual? It is aping the working pattern of specialists in developed countries. Developed countries have many more mental health specialists per head of population. They are relatively well-paid in both public and private sectors and they work within health services with the support of highly resourced multi-disciplinary community mental health care and social welfare systems. All this leaves specialists pretty much free to focus on the narrow realms of clinical practice and management.
But in developing countries, if we continue to focus almost entirely on hospital or clinic based patient management, the specialist mental health professions will remain, at best, only a marginal player in improving mental health care.
It is time for us to reassess the role of specialists. This role should be shifted principally to four tasks: designing mental health care programmes that can be delivered by non-specialists; building their health system's capacity for delivering care, particularly by supporting front-line health workers; raising awareness of mental disorders and patients' rights; and essential research. To do this we must reorientate training for mental health specialists, ring-fence time for these activities in job contracts, and provide incentives for community engagement.
The evidence base
Some will question whether transferring mental health care to lay health workers is an effective and safe strategy. In fact, almost all the evidence on effective interventions for mental disorders in developing countries suggests there are advantages in strategies that shift tasks to informal health workers.
One excellent example has been interpersonal therapy (a psychological treatment for depression) in rural Uganda. There, randomised trials studied treatment delivered by appropriately trained and supervised lay people, and found it to be very effective.
Of course, human resources shortages are not confined to mental health alone. Developing countries are already advocating and evaluating this sort of task-shifting strategy for a wide range of other health concerns, such as maternal and child health.
Getting the donor's attention
The apparent disinterest of many major global health agencies towards mental disorders is hindering improvement in developing countries' mental health services. Undoubtedly, there has been an increased acknowledgement of mental health in recent years, but the truth remains that most global health initiatives continue to relegate mental disorders to the shadows.
The stigma mental illness carries must play a role in explaining this denial, but so too does the archaic view that mental health is not relevant to global health, that suffering from an infectious disease like TB is more important to individuals than suffering from schizophrenia, that investments in mental disorder care are not cost-effective, or that people who are poor do not consider mental health as a valued personal good.
This is a curious situation given the considerable evidence about the burden and treatability of mental disorders in developing countries. It is even more curious given that most of the agencies and individuals that set global health priorities live in rich countries whose health systems heavily invest in mental health. It seems those who already have good mental health care believe that people in poor countries have more serious issues to deal with than mental disorder. I cannot imagine why else global health initiatives systematically ignore mental disorder.
Raising the profile of mental health requires advocacy, not just with local communities, but with the global experts who set the health agenda for the developing world. Those who acknowledge the problem and recognise the potential solutions must continuously engage with experts, disseminate information through media, strengthen the voices and capacity of the patients' movement, and highlight the unacceptable human rights violations of people suffering with mental disorders. And, if all else fails, we must 'name and shame' those who continue to ignore the suffering of hundreds of millions of children and adults who struggle with treatable mental health problems.
Jane Dunn ( United States of America )
18 May 2009
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