Mental Health Care in the Developing World

Psychiatric Times

January 2002

Vol. XIX

Issue 1

Some 450 million people worldwide currently suffer from some form of mental disease or brain condition, but almost half the countries in the world have no explicit mental health policy and nearly a third have no program for coping with the rising tide of brain-related disabilities.

These findings were included in a major report by the World Health Organization (WHO) released in October 2001. The report, titled Mental Health: New Understanding, New Hope, was the culmination of a year-long effort that included devoting World Health Day to the subject of mental illness last April and the publication of a detailed survey of the status of treatment of mental conditions in developing countries.

"The WHO is making a simple statement: mental health -- neglected for far too long -- is crucial to the overall well-being of individuals, societies and countries and must be universally regarded in a new light," according to a statement by Gro Harlem Brundland, M.D., Director General of the WHO.

"It is time for governments to make mental health a priority and to allocate the resources, develop the policies and implement the reforms needed to address this urgent problem. One in four people will suffer from mental illness at some time in life," added United Nations Secretary General Kofi Annan.

The WHO also launched a new worldwide effort called Project Atlas to catalogue mental health resources around the world. In its initial survey, the project found that, of the countries it surveyed:

• 41% have no mental health policy.
• 25% have no legislation on mental health.
• 28% have no separate budget for mental health.
• 41% do not have treatment facilities for severe mental disorders in primary health care.
• 37% have no community health care facilities.
• About 65% of the beds for mental health care are in mental hospitals.

In the United States, the Institute of Medicine (IOM) issued a detailed look at the state of treatment for brain disorders in developing countries. While much of the IOM's attention recently has been focused on the aftermath of the terrorist attacks on the United States, a number of new initiatives are being planned to implement the study's recommendations.

Neurological and psychiatric disorders constitute an often unseen but growing problem in developing countries, according to a report issued by the IOM, which added that statistical measures barely begin to encompass the degree of suffering they cause.

"Brain disorders are responsible for at least 27 percent of all years lived with disability in developing countries," the authors wrote. "When disability is taken into consideration along with death, brain disorders comprise nearly 15 percent of the burden of disease in developing countries."

Epilepsy, depression, bipolar disease, schizophrenia, developmental disorders and stroke "are currently estimated to affect as many as 1.5 billion people worldwide -- a number that is expected to grow as life expectancy increases. Since most disorders affecting the brain and its neural connections result in long-term disability and many have an early age of onset, measures of prevalence and mortality vastly understate the disability they cause."

The report, Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World, was published by the IOM in May 2001 and examines the medical, sociological and economic implications of brain disorders in parts of the world where "diagnoses of mental disorders, including depression, have no conceptual equivalent in many languages."

In describing the scope of the problem, the authors pointed out that health policy has long been limited by the following misperceptions about brain disorders: they are a problem in the developed but not the developing world, they do not cause mortality, they are not amenable to treatment, and they are too expensive to manage.

But, the authors said, such policies ignore the magnitude of the problem. Brain disorders already represent the leading cause of a "large proportion of the burden of disease in developing countries." As a result of demographic shifts, brain disorders are projected to increase. By 2020, stroke and depression will rank first and second as the leading causes of disability worldwide.

Furthermore, the stigma associated with many brain disorders, such as epilepsy, schizophrenia and mental retardation, prevents people in developing countries from seeking and receiving appropriate treatment. In addition, it may result in the loss of social and educational opportunities for both the sufferers and their families.

Poverty can also be both a cause and a result of ill health and may contribute to brain disorders through poor nutrition, unhygienic living conditions and inadequate access to health care. According to the report, research indicates that in many countries "poverty and several psychiatric disorders, such as depression, exacerbate each other."

In addition, the report noted that many countries do not have adequately trained medical and nursing professionals to deal with brain disorders. "In India, for example, there are about 3,000 psychiatrists and 565 neurologists to serve a billion people, while in Zimbabwe there are 10 psychiatrists and 29 neurologists to serve 11 million people," the authors wrote.

The study examined six types of disorders individually, assessing the current state of medical care as well as the ramifications of each condition and the prospects for improved policies.

Epilepsy affects an estimated 40 million people in developing countries, accounting for approximately 85% of people with the disease worldwide. But because of the social stigma associated with the disease, it frequently goes untreated in these areas.

Developmental disabilities that can result from genetic and nutritional factors, infectious diseases, and traumatic events are virtually unrecognized in many third-world countries. But as many as 80% of the world's children are born in those countries, where nutritional deficiencies, environmental toxins and perinatal complications are prevalent.

Although the report noted that bipolar disorder accounts for about 11% of the neuropsychiatric disease burden in developing countries, and preliminary population-based studies have shown suicide rates may be as high as 24%, the authors conceded that little is known about its incidence both in developed and developing countries.

"Despite the identification of bipolar disorder early in the 20th century and prevalence rates in developed countries that are higher than those for nonaffective psychoses, less research has been conducted in these countries on this disorder in comparison to other psychiatric conditions [including those discussed elsewhere in this report]," the authors wrote. "In developing countries, an even smaller and similarly inconclusive body of research exists."

Depression is estimated to be the leading cause of disability worldwide, but because it is not even acknowledged as a major disease in many countries, there is little in the way of accurate statistical data on its prevalence in developing countries. The study reported that countries like Sri Lanka and China have the highest rates of suicide in the world, but added, "In non-Western countries...completed suicides may be less likely to have received a psychiatric diagnosis because of the paucity of mental health services."

Schizophrenia affects an estimated 33 million people in developing countries, with an average lifetime risk of about 1%. But, the study noted, "The social and economic costs of schizophrenia are disproportionately high relative to its incidence and prevalence...In terms of DALYs [disability adjusted life years], predicted demographic trends include more than a 50 percent increase in the disease burden attributable to schizophrenia in developing countries, a burden approaching that of malaria and nutritional deficiency."

In both developed and developing countries, the burden of schizophrenia includes a high degree of stigmatization and social rejection. "Many schizophrenic patients end up on the streets or in the criminal justice system and are exposed to abuse, even in psychiatric hospitals."

While many patients with schizophrenia respond to treatment, the authors found that relatively few developing countries are taking steps to provide care. "It is estimated that in 1990, over 67 percent of all persons with schizophrenia in developing countries [estimated at 17.2 million] were not receiving any treatment, and there is no evidence that the proportion of treated persons is increasing."

The authors recommended that governments and agencies responsible for social and medical policy in developing countries be made aware of "the fact that schizophrenia and other psychotic illnesses are treatable conditions and that significant returns in terms of symptom control, quality of life and reintegration into the community can be achieved if increased funding is provided for local and regional programs that incorporate best-practice procedures and criteria."

Stroke is projected to become the fifth leading condition contributing to the disease burden in developing countries by 2020. Prevention programs are essential to holding this increase in check, but the study found that risk factors are increasing in many developing countries. "The growing adoption of behaviors and lifestyles known to elevate stroke risk, such as tobacco use and high saturated fat intake" will continue to exacerbate the risk of stroke and other vascular diseases. "Current predictions indicate that by 2020, 12 percent of all deaths and nine percent of all DALYs will be attributable to tobacco alone; the vast majority of this increased burden is projected to arise in developing countries."

More money and resources are the solutions to many of the problems involved in treating brain disorders in developing countries. "Where resources are scarce," the authors wrote, "policy makers face difficult choices in allocating limited funds for health care. Such decisions are best made on the basis of rigorous evaluation of the efficacy of proposed interventions and, for those interventions that prove efficacious, their cost effectiveness."

Despite the obstacles, however, the researchers found numerous examples of innovative and cost-effective programs in a handful of developing nations.

In Tanzania, a country that spends only about US$1.33 per capita annually on health care, self-sustaining villages for the care of individuals with chronic psychiatric disorders have been created.

In Malawi, a community education and publicity campaign is moving patients with epilepsy away from traditional healers and into modern hospitals. To overcome distance problems in a country without adequate public transportation, two mobile clinics have been established.

In Iran, a village-based primary care system serves over 60 regions of the country, with the village centers linked to surrounding hospitals and medical schools. The national health program supports training in mental health care for all personnel and the development of a district-level mental health care support system, and it sponsors an annual mental health care week. In addition, the government has established an urban mental health program and created four regional centers for the prevention of mental disorders, with an emphasis on depression and suicide. Officials are also developing a school mental health care program and a child abuse prevention program.

In Bangladesh, the Shishu Bikash Kendro Child Development and Neurology Center at Dhaka Shishu Hospital focuses on cerebral palsy, epilepsy and developmental delay. In addition, it trains paramedical workers in occupational therapy, speech therapy and physiotherapy to broaden its outreach.

In China, physicians at the Beijing Neurosurgical Institute worked with colleagues from University of Washington to develop pilot stroke-prevention programs involving 10,000 subjects in two widely separated cities. The programs featured screening for hypertension, heart disease and diabetes, as well as lifestyle modification.