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Learning from Low to Middle Income Countries

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Introduction
Publications
Research and Practice
Videos and Presentations
Organisations
Links


Introduction

There is much to be learnt in western countries from the holistic approach practiced in some developing countries. nThe World Health Organization (WHO) sponsored major studies comparing how people recover in poor and more developed nations. The people in the poorer developing nations, on average, recovered at a far higher rate. 

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Publications (date ordered)

Mental Health Worldwide: Culture, Globalization and Development by Suman Fernando Palgrave Macmillan, ISBN 1137329599 Mental Health Worldwide offers a perceptive critique of the universalized model of psychiatry and its apparent exportation from the West to the developing world. The foundational concepts of the dominant models in psychiatry, however, are understood very differently in non-western cultural traditions. Whilst there is a worldwide need to emphasize mental health in the context of public health, the 'traditional psychiatric' model, with its focus on medicalization and drug-based 'cures', may not always be appropriate, and its approaches should not be employed unquestioningly. Here, Suman Fernando takes a much-needed critical look at the field of psychiatry in an international context, proposing suggestions for advancing mental health and wellbeing in low and middle income countries in a way that is ethical, sustainable and culturally sensitive. These lessons can also be applied to developing service provision in the West in our increasingly globalized world.

 

 

Recovery from Schizophrenia: An International Perspective: A Report from the WHO Collaborative Project, the International Study of Schizophrenia Kim Hopper (Editor), Glynn Harrison (Editor), Aleksandar Janca (Editor), Norman Sartorius (Editor) Oxford University Press, 2007. In the late 1960s, the World Health Organization initiated a series of international studies of the incidence, characteristics, course, and consequences of schizophrenia. Those studies - the largest ever in the history of psychiatry - provided important data about the disorder in groups of patients living in different countries and cultures, and first focused attention on the differences in short-term prognosis for schizophrenia between the third world and industrialized countries. In the 1990s, the International Study of Schizophrenia (ISoS) set out to relocate those subjects and to determine their clinical and social status some 15 to 25 years later. Recovery from Schizophrenia is a comprehensive account of what ISoS found, reporting follow-up results for over 1000 subjects examined in the earlier WHO studies (and in several local studies as well). The body of this volume consists of detailed descriptions of the long-term course and outcome of schizophrenia, together with portraits of the field research sites in 14 countries. Introductory and synoptic chapters lay out the origin and design of the WHO studies culminating in ISoS, and synthesize the study's main findings. ISoS shows that, with appropriate treatment, schizophrenia has a favorable outcome for a substantial portion of those afflicted. The surprising finding of the short-term follow-up studies - that outcome was better in the developing than in the developed countries - is confirmed here for long-term course. Yet while prognosis continues to favor subjects in developing countries, the varied outcomes for those in developed nations still offers ample reason for hope. This book is the first of its kind. The massive multinational investigations upon which it is based are unique in psychiatry and cross-cultural epidemiology. Recovery from Schizophrenia will be a valuable resource for researchers, epidemiologists, policymakers, and mental health professionals worldwide, providing evidence that supports investment in the care of persons with schizophrenia.

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Research and Practice

The ‘better prognosis hypothesis’ for schizophrenia in poor countries. Is it the medication? Glenn Brady, in2mentalhealth, October 5, 2014  Since decades the ‘better prognosis hypothesis’ keeps looming in international research and debates. It’s the assumption, or conclusion, from international research, that outcomes for schizophrenia are better in developing countries compared with developed countries. This complex matter continued to intrigue me. Suppose there is a difference in the course of schizophrenia between rich and poor countries (and sometimes it seems there is), what could we learn from this? Could this give us answers on how to treat people with (and after) a psychosis? Could it give us clues for more effective models of care, new protocols, new ideas and inspiration for the difficult roads to recovery? And what is the role of medication? Must we stick to the current biomedical model of treatment? Still, in all the efforts to get a definitive and clear confirmation or rejection of this best prognosis hypothesis, more and more new questions seem to arise. Controversies about the research quality and validity, as well as the conclusions drawn from the data, are not solved yet.

Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial Sudipto Chatterjee, Smita Naik, Sujit John, Hamid Dabholkar, Madhumitha Balaji, Mirja Koschorke, Mathew Varghese, Rangaswamy Thara, Helen A Weiss, Paul Williams, Paul McCrone, Vikram Patel, Graham Thornicroft The Lancet, March 5, 2014. Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middleincome countries. We did the COmmunity care for People with Schizophrenia in India (COPSI) trial to compare the eff ectiveness of a collaborative community-based care intervention with standard facility-based care.

Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India Sudipto Chatterjee, Aravind Pillai,  Sumeet Jain,  Alex Cohen, Vikram Patel  Background There is little evidence of the feasibility, acceptability and impact of services for the care of people with psychotic disorders in low- and middle-income countries. Aims To describe the scaling up and impact of a community-based rehabilitation programme for people with psychotic disorders in a very-low-resource setting. Methods Longitudinal study of people with psychotic disorders who had been ill for an average of 8 years in a rural Indian community. All individuals received a community-based intervention package comprising psychotropic medications, psycho-education, adherence management, psychosocial rehabilitation and support for livelihoods. The primary outcome was change in disability scores. Results The cohort consisted of 256 people with psychotic disorders (schizophrenia, bipolar affective disorder and other psychosis) of whom 236 people completed the end-point assessments (92%), with a median follow-up of 46 months. There were significant reductions (P<0.05) in the levels of disability for the cohort, the vast majority (83.5%) of whom engaged with the programme. On multivariate analyses, lower baseline disability scores, family engagement with the programme, medication adherence and being a member of a self-help group were independent determinants of good outcomes. Lack of formal education, a diagnosis of schizophrenia and dropping out of the programme were independent determinants of poor outcomes. Conclusions Community-based rehabilitation is a feasible and acceptable intervention with a beneficial impact on disability for the majority of people with psychotic disorders in low-resource settings. The impact on disability is influenced by a combination of clinical, programme and social determinants.

Mental health in the developing world: time for innovative thinking Vikram Patel, psychiatrist and senior lecturer at the London School of Hygiene Tropical Medicine, Sci Dev Net, 2008 Developing nations must stop aping the North's mental health services and use strategies tailored to their own needs,

Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World?  Alex Cohen, Vikram Patel, R. Thara, and Oye Gureje Schizophrenia Bulletin vol. 34 no. 2 pp. 229–244, 2008 That schizophrenia has a better course and outcome in developing countries has become an axiom in international psychiatry. This is based primarily on a series of cross-national studies by the World Health Organization (WHO). However, increasing evidence from other research indicates a far more complex picture. Methods: Literature review and tabulation of data from 23 longitudinal studies of schizophrenia outcomes in 11 low- and middle-income countries. Results: We reviewed the evidence about the following domains: clinical outcomes and patterns of course, disability and social outcomes (marital and occupational status, in particular), and untreated samples and duration of untreated psychosis. Outcomes varied across the studies and the evidence suggests a need to reexamine the conclusions of the WHO studies. Additionally, assessments of outcomes should take excess mortality and suicide into account. Conclusions: It is time to reexamine presumed wisdom about schizophrenia outcomes in low- and middle-income countries.

Schizophrenia outcomemeasures in the wider international community  MOHAN ISAAC, PRABHAT CHAND and PRATIMA MURTHY, BRITI SH JOURNAL OF P SYCHIATRY ( 2 0 0 7 ) , 1 91 ( s u p pl . 5 0 ) Background Outcome of schizophrenia hasbeen described as favourableinlow- andmiddle-income countries.Recently, researchershave questionedthese findings. Aims To examine the outcome studies carried out in differentcountries specificallylookingatthose fromlow- and middle-income countries. Methods Long-termcourse and outcome studies in schizophreniawere reviewed. Results Awide varietyofoutcome measures are used.Themost frequent are clinical symptoms, hospitalisation and mortality (direct indicators), and social/ occupational functioning,marriage, social support and burden of care (indirect indicators).Areas such as cognitive function, duration of untreatedpsychosis, qualityof life and effectofmedicationhave not beenwidely studiedinlow- and middle-income countries. Conclusions The outcome of schizophrenia appears to be betterinlowandmiddle- income countries. A host of sociocultural factorshave been cited as contributing tothisbut future research should aimto understandthisbetter outcome.Thereis aneedformoreculturespecific instruments tomeasure outcomes.

Treatment and prevention of mental disorders in low-income and middle-income countries Prof Vikram Patel, l, Prof Ricardo Araya, Sudipto Chatterjee, Dan Chisholm, Alex Cohen, Mary De Silva,  Prof Clemens Hosman, Hugh McGuire,  Graciela Rojas, Mark van Ommeren, The Lancet, Volume 370, No. 9591, p991–1005, 15 September 2007 We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak—especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Destigmatizing day-to-day practices: what developed countries can learn from developing countries Alan Rosen, World Psychiatry. 2006 Feb; 5(1): 21–24. The nature of and threshold for stigma associated with mental disorders appears to be different between developed and developing countries. Decreasing stigma can be achieved through a combination of the best Western educational and media strategies and the systematization of some important lessons from developing countries. At the macro-level, this involves: societal changes leading to being more inclusive and re-integrating people with mental illness into our communities; finding socially useful and culturally valued work roles for such marginalized people; re-extending our kinship networks, and re-valuing contact with people with mental illness and learning from their experiences. At the micro-level, this involves developing more destigmatizing day-to-day clinical practices, including: more holistic appraisal of disorder, abilities and needs; therapeutic optimism; a strengths orientation; engaging family and redeveloping an extended support network; celebration of age appropriate rites of passage; invoking the language of recovery; valuing veterans of mental illness as "spirit guides"; promoting consumers' community living as full citizens; engaging and involving the local community in taking responsibility for their own mental health.

Poverty and common mental disorders in developing countries Vikram Patel & Arthur Kleinman, Bulletin of the World Health Organization 2003;81:609-615. A review of English-language journals published since 1990 and three global mental health reports identified 11 community studies on the association between poverty and common mental disorders in six low- and middle-income countries. Most studies showed an association between indicators of poverty and the risk of mental disorders, the most consistent association being with low levels of education. A review of articles exploring the mechanism of the relationship suggested weak evidence to support a specific association with income levels. Factors such as the experience of insecurity and hopelessness, rapid social chan- ge and the risks of violence and physical ill-health may explain the greater vulnerability of the poor to common mental disorders. The direct and indirect costs of mental ill-health worsen the economic condition, setting up a vicious cycle of poverty and mental disorder. Common mental disorders need to be placed alongside other diseases associated with poverty by policy-makers and donors. Programmes such as investment in education and provision of microcredit may have unanticipated benefits in reducing the risk of mental disorders. Secondary prevention must focus on strengthening the ability of primary care services to provide effective treatment.

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Videos and Presentations

Democratising Mental Health Persons living with mental and substance abuse problems, and their families are often stigmatised by societies. Democratising Mental Health is a short documentary film (9 mins) set in Nepal told from a patient perspective. It takes the viewer on a journey of a family's search for mental health care, including their interactions with traditional health systems. Along their journey, they come across people working for PRIME, which is engaging in people-centred strategies to integrate mental health into the primary health care system, and to give a voice to those who are typically marginalised in low and middle-income countries. In addition to alcohol use disorders, PRIME also identifies depression (including maternal depression), psychosis (notably schizophrenia), and epilepsy as priority mental disorders.

GO AWAY EVIL Buyiswa's Mental Health Story There are over 300 million people afflicted with mental illness living in the developing world, and 8 out of 10 of these people will be left untreated. In this short film Buyiswa talks about how she overcame her mental illness and how treatment transformed her life. A Film by Delaney Ruston, MyDoc Productions (www.unlistedfilm.com).

Suman Fernando - Challenges for Mental Health Development in Low and Middle-income Countries Community mental health services everywhere in the world should: aim to meet the mental health and social care needs of people as perceived by people themselves; be relevant and sensitive to local conditions and cultures; involve all stakeholders including marginalised groups; and be culturally and economically sustainable. In planning services in LMI countries, cross-cultural psychiatric research carried out using psychiatric diagnostic categories are of limited use, but there are some pointers that may help. "Mental illness" identified in a psychiatric model, during the 1960s and 1970s, had better outcomes in LMI countries (compared to that in the (then) industrially-developed countries) although this "better outcome" may no longer be as evident, since the spread of westernisation. It seems that attendance at healing centres in South India may provide as much benefit for people diagnosed as "schizophrenic' as psychiatric treatment, and that the best system may be one where people suffering psychological distress and their relatives have a choice as to what system they access for help. The "global mental health" movement being pursued by the US NIMH requires considerable modifications if it is to be ethically acceptable in a post-colonial world. Otherwise, the result will be the imposition of Euro-American psychiatry en masse, amounting to cultural imperialism. The present priorities for alleviating mental distress in LMI countries include: developing social support and community development -- for example, to re-build communities disrupted by the effects of war, civil conflict and natural disasters; addressing breakdown of social systems resulting from rapid industrialization and urbanization; counteracting the effects of poverty and oppression; and providing human-rights sensitive ways of controlling people who are behaviorally disturbed. Also, there is an urgent need for regulating the marketing of psychoactive drugs in order to prevent the exploitation of vulnerable people in LMI countries.

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Organisations

Sangath is a non-governmental, not-for-profit organisation committed to improving health across the lifespan by empowering existing community resources to provide appropriate physical, psychological and social therapies. Its primary focus areas include child development, adolescent and youth health, and mental health and chronic disease. Started in 1996, it began as Goa’s first multi-disciplinary child development clinic based in Porvorim through the voluntary contributions of its seven founder-members. Sangath has now stretched its reach to become one of the state’s most influential health NGOs garnering local, national and international recognition.

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Links

World Health Organization Study Comparing Mental Health Recovery in Developed & Developing Nations The World Health Organization (WHO) sponsored major studies comparing how people recover in poor and more developed nations. The people in the poorer developing nations, on average, recovered at a far higher rate. Here is information about those studies. MindFreedom asked Professor Norman Sartorius to briefly summarize these studies, which he was directly involved in leading. The views expressed are those of Dr. Sartorius.

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